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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005617
Report Date: 08/06/2021
Date Signed: 08/08/2021 04:39:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/01/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210601163155
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: 3DATE:
08/06/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:T KoayenTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident received a burn while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson arrived unannouced to the facility to deliver findings for the complaint investigation dated 6/1/2021. LPA met with David Blaine. Later joined by Tannch koayen

Allegation:Staff did not provide adequate supervision to resident's in care. Based on interviews conducted and records reviewed LPA was able to confirm that R1 suffered burns while in care.

It was reported that on Saturday 5/29/2021 at about 3pm, The facility smelled gas in the house and everybody was removed from the house immediately. PG&E was called and they shut off the gas. They then, checked the house and noticed one of the cooker burner was not tight and they therefore tightened it.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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-20210601163155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WALTERS RESIDENTIAL HOME CARE
FACILITY NUMBER: 397005617
VISIT DATE: 08/06/2021
NARRATIVE
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They then turned the gas back on and reset all the settings (stove, water heater and other).

On Monday 5/31/2021, Staff was in the process of given R1 shower in the tub. R1 reached to the faucet and turned it to the hot water and it burnt his butt. 911 was call immediately, and he was taken to San Joaquin General Hospital and later to UC Davis Medical Hospital.

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.

As a result of this incident, and R1 sustaining serious bodily injury/death, the violation warrants a civil penalty assessment. At this time, the civil penalty assessment is under review, and a civil penalty determination is pending by the department. Once civil penalty assessment has been determined, a LPA will return at a future date to assess the civil penalty.

Exit interview conducted and copy of report, 9099-D, LIC 811, and appeal rights provided.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210601163155
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2021
Section Cited
CCR
85077(a)
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85077 Personal Services. (a) Licensees shall provide necessary personal assistance and care, as indicated in the needs and services plan, with activities of daily living including but not limited to dressing, eating, and bathing.
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Licensee/Administrator agree to conduct staff training on water temperatures and safety while caring for residents.
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This is not met as evidenced by Staff did not make sure the water temperature was safe resulting in R1 getting burned. This is an immediate health and safety risk to residents in care.
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Documentation of training agenda/attendees to be provided to CCLD by fax by 08/09/21.
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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: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3