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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:44:27 PM


Document Has Been Signed on 11/10/2022 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:CHARLES WHITEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: DATE:
11/10/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:CHARLES WHITETIME COMPLETED:
04:00 PM
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Licensing Program Analyst Kesha Lewis and Albert Johnson arrived unannounced to conduct a POC visit from 9/29/202022. LPA was greeted by Administrator.

Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC.

Facility was provided POC cleared letter.

Exit interview conducted and a copy of this report was left at the facility.



SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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