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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 12/01/2022
Date Signed: 01/30/2023 02:53:38 PM


Document Has Been Signed on 01/30/2023 02:53 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: 45DATE:
12/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Yvonne HernandezTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced Case Management visit to follow up on an two (2) incidents, which occurred on 11/13/22 and 11/15/2022. LPA explained purpose of visit to staff.

In both incidents on 11/13/22 and 11/15/22 R1 requested to go to the hospital as they were in pain. R1's responsible party and physician were informed on the incident.

LPA reviewed R1'S file including the LIC 602 (Physician's report) and discharge paperwork. R1 is being treated by Stockton Pace for Impetigo, Pruritic rash and pneumonia. R1 is currently being quarantined. New medication was prescribed to treat conditions and Physician was notified.

No Deficiencies were observed.

Exit interview conducted with Staff and a copy of report was left at facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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