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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 06/29/2023
Date Signed: 08/04/2023 05:40:26 PM


Document Has Been Signed on 08/04/2023 05:40 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:MANISHA PUNNIFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:80CENSUS: DATE:
06/29/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Facility RepresentativesTIME COMPLETED:
09:46 AM
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A Non-Compliance Conference (NCC) was conducted on this day, 06/29/2023, by the Sacramento South Regional Office via Teams meeting. This Noncompliance Conference was called to discuss the following issues or deficiencies: Care and Supervision, Incidental Medical Care, Personal Rights, Maintenance and Operation, Managed Incontinence Present in the meeting was Regional Manager (RM), Stephenie Doub, Licensing Program Manager (LPM), Liza King,Licensing Program Analyst (LPA) Kesha Lewis, Manisha Punni Administrator, Rosalie Sullivan facility representative Kevin Phomthevy department of health care services, Bailey Douglas department of health care services, Andrew Chen department of health care services and Kathryn Thomas ombudsmen.
The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. RM, LPM and LPAs discussed the following citations and the associated plans of correction going forward. Please note some citations may are under appeal at this time:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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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