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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 03/18/2022
Date Signed: 03/22/2022 06:19:22 AM


Document Has Been Signed on 03/22/2022 06:19 AM - It Cannot Be Edited

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:GURPREET RAIFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 52DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Gurpreet Rai, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Bruce Jacobs met with Facility Administrator Gurpreet Rai to conduct a required 1-year annual inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 80 residents. The facility has 52 currently with one resident on hospice and one receiving outside wound care. The residents were observed in the activity room playing bingo. The facility has submitted and is following their Mitigation Plan and the focus of this evaluation was on infection control procedures and processes.

LPA toured the facility including but not limited to apartments, bathrooms, kitchen, dining room areas, common area and outside area.. All outdoor and indoor passageways observed were kept free of obstructions. A comfortable temperature throughout the facility is maintained at 76 degrees Fahrenheit. Water temperature was tested at 113.5 degrees F. in the bathrooms. Medications and toxins were locked and inaccessible to residents in care. No other hazards were observed in the facility LPA observed lighting in apartments are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid floors. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods and LPA observed today's lunch.

Fire extinguishers were last serviced in July 2021 and are in compliance. A Fire Department inspection was completed in December 2021 and the facility passed the inspection. The inspection included tests on the alarms on doors, fire extinguishers, smoke detectors and alarm system. Emergency Disaster Plan was posted. Continued
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306
VISIT DATE: 03/18/2022
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LPA interacted with several residents, with staff and met with Corporate representatives. Administrator's Certification for Facility Administrator Rai is # 6059423740 expires 3/23/2023.

Updated copies of the following documents as needed were requested for facility file and are to be submitted to CCLD by 4/18/2022: LIC 308 Designation of Administrative Responsibility, LIC 309 Administrative Organization, LIC 500 Personnel Report, copy of Liability Insurance and current surety bond.

No deficiencies cited during inspection. Exit interview conducted with Administrator Gurpreet Rai.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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