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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005617
Report Date: 09/07/2022
Date Signed: 09/07/2022 01:14:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2022 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220901155021
FACILITY NAME:WALTERS RESIDENTIAL HOME CAREFACILITY NUMBER:
397005617
ADMINISTRATOR:MOSES WALTERS SR.FACILITY TYPE:
735
ADDRESS:2746 ABRUZZI COURTTELEPHONE:
(510) 688-3552
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 4DATE:
09/07/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tannch KoayenTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility's window is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis and Albert Johnson arrived unannounced to the facility to deliver findings for the complaint investigation dated 9/1/2022. LPA met by David Blaine. Later joined by Tannch koayen

Allegation: Facility's window is in disrepair.

Based on LPA'S observation a temporary window is in place and the permanent window was ordered. It will take 7-10 day to receive the order then a installation date will be set. Copy of receipt taken. LPA's reviewed the IPP for R1 and observed that R1 has a history of property destructions. R1 has a behavior plan in place to address this maladaptive behavior.

Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220901155021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WALTERS RESIDENTIAL HOME CARE
FACILITY NUMBER: 397005617
VISIT DATE: 09/07/2022
NARRATIVE
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As a result of this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. It was reported that on 9/01/2022 that the facility had a broken window since 8/27/22.

Exit interview conducted and copy of report, 9099-D, appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20220901155021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WALTERS RESIDENTIAL HOME CARE
FACILITY NUMBER: 397005617
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
09/30/2022
Section Cited
CCR
80087(a)
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80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.

This requirement is not met as evidenced by observation of the facility during tour/inspection
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The facility will repair or replace the
window listed by the POC date or submit a plan to repair or replace and submit receipts or repair orders by email to CCL.
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LPA'S observation a temporary window is in place and the permanent window was ordered. It will take 7-10 day to receive the order then a installation date will be set. Copy of receipt taken. This poses a potential health risk to clients in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3