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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005617
Report Date: 08/01/2022
Date Signed: 08/05/2022 12:01:44 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
06/01/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220601114929
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:
08/01/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:David BlaineTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident's furniture is in disrepair.
Facility is in disrepair.
Smoke Detector not working.
Facility has not conducted disaster drills for residents.
Residents do not have access to food.
Resident's file is not up to date.
INVESTIGATION FINDINGS:
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Based on the observation of the allegations and the interview with the house manager on 6/2/2022 the allegations are substantiated. The facility has corrected the allegation and sent supporting documents and picture on 6/6/2022 to show that the item listed above have been addressed / or corrected. The Administrator stated that the allegations are true, however, the residents in the facility have documented information in their IPPs' about property destruction, aggressive action both verbally/ physically and stealing food. LPA was able to take pictures of the allegations during the initial opening of the complaint and was able to substantiate the allegations listed.

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.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022
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-20220601114929
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: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2022
Section Cited
CCR
80020
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FIRE CLEARANCE Facility has failed to maintain the fire clearance. The smoke detectors was inoperable smoke detectors presents a threat to the safety of facility residents and violates the conditions of the facility fire clearance.
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Corrected
Type B
08/05/2022
Section Cited
CCR
80023(d)
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Disaster and Mass Casualty Plan: Disaster Drills shall be conducted at least every six months. Records of the fire drill was not available for review. There is no record of fire drill conducted at the facility.
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Licensee/administrator shall ensure that fire drills are conducted every six months for safety.

Corrected
Type B
08/05/2022
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds



(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The couches at the facility are torn and have significant wear
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The facility will replace or repair the couches and any other furniture that is torn or has heavy wear.
Type B
08/05/2022
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons. the facility locked the snack cabinet
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The facility shall have snacks available for residents unlocked and accessible at all time.
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: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220601114929
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: 08/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2022
Section Cited
CCR
80069(a)
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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
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Licensee will obtain necessary documents and submit proof on or before POC date.
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1. Personal property log has not been updated
2. Functional assessment has not been updated
3. P&I – no receipts, missing signatures
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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: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3