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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:35:50 PM

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: 63DATE:
09/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Katrice Collins, Facility AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Bruce Jacobs conducted a case management visit at the facility to discuss incident reports to be submitted to the Department. LPA met with Administrator Katrice Collins and the purpose of the visit was disclosed. Licensing received information from the Local Health Department that resident(s) had tested positive for an infectious disease and this information was not reported to the Department by the facility. The facility confirmed that they have not had any recent positive cases and all cases were reported, with the last one being on 8/16/21. The Administrator stated that the neighboring Skilled facility with a similar name has had cases and might have been confused with the Assisted Living facility. LPA called Department of Public Health and left a message, but the call was not returned by the conclusion of the visit. LPA will further follow-up with DPH.. Upon further review it was determined that the lab did detect a positive case on 9/2/21, but had not notified the facility until the facility inquired into the report, test results and lines of communication on tis date. The facility was never notified by the lab of a positive test result.

No deficiencies are issued at the time of this visit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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