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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 09/28/2020
Date Signed: 09/28/2020 10:14:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:COLLINS, KATRICEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 55DATE:
09/28/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:ADMINISTRATOR - KATRICE COLLINSTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPA's) Ruth Wallace and Ashley Boothe conducted an unannounced case management visit. Met Administrator to explain the reason for visit which is to conduct interviews with staff for three open complaints.

LPA's interviewed four staff that work various shifts at the facility.

No deficiencies cited on today's visit.

Exit interview with Administrator Katrice Collins.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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