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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 06/20/2023
Date Signed: 07/10/2023 09:27:50 AM


Document Has Been Signed on 07/10/2023 09:27 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:MANISHA PUNNIFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: 51DATE:
06/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:MANISHA PUNNITIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kesha Lewis conducted an unannounced Case Management visit to follow up on (3) three incidents, which occurred on 06/10/23 and 06/13/2023. LPA explained purpose of visit to Administrator.

In the incidents R1- R3 were sent to the hospital. LPA reviewed R1'S - R3'S file including the LIC 602 (Physician's report) and discharge orders from the hospital. All needs and services plans had been updated and new medications being given. R2 is still in the hospital pending biopsy.

No Deficiencies were observed.

Exit interview conducted with administrator and a copy of report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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