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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 12/14/2020
Date Signed: 12/15/2020 03:49:15 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: 40DATE:
12/14/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Lisa Clayton IP, RN, Dr. Otashea Golden (Facility Physician) and Jacquelin Turner, Director of Regulatory affairs , Lisa Pearson, Vice President of Northern, LVN, Karol Ford Administrator.
TIME COMPLETED:
04:30 PM
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 Licensing Program Analyst (LPA) Albert Johnson, Licensing Program Manager (LPM) Liza King, Regional Manager (RM) Krystall Moore, Clinical Myra Cunanan and SJC health department Pam Costamagna. The team met with acting- Administrator Marivek Andrade, Lisa Clayton IP, RN, Dr. Otashea Golden (Facility Physician) and Jacquelin Turner, Director of Regulatory affairs , Lisa Pearson, Vice President of Northern, LVN, Karol Ford Administrator.

Marivek is the facility contact related to COVID and Administrative documents can be requested from Katrice Collins (Administrator) who is working from home.

The department has requested an updated list of the Covid positive resident to include the DOB and symptom column to be completed. In addition, the LPM requested the following columns to be added to include current location and ethnicity. The facility has completed mass testing and is awaiting result for the whole facility. No staffing concerns or a need for additional PPE at this time.

The facility will send the new positives medical necessity transfer, Physician orders, lab results and emergency contact info via email to LPM by 12/15/2020. The department has scheduled daily health and safety/wellness calls at 1pm daily .
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2020
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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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: 12/14/2020
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The facility sent out two residents on 12/4/2020 and 12/7/2020 to the emergency room (ER). The facility did not submit an incident report to the Department for these ER visits/incidents. An advisory was given for reporting requirements, based on interviews with the Administrator and records reviewed.

Exit interview was conducted with facility representative where LPA reviewed report. An electronic copy of the report was emailed to the facility to obtain a signature from the representative and emailed back to LPA to be filed.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2020
LIC809 (FAS) - (06/04)
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