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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 11/02/2023
Date Signed: 11/02/2023 07:54:44 PM


Document Has Been Signed on 11/02/2023 07:54 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: 66DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:MANISHA PUNNITIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to open an complaint for the above allegations. LPA was greeted by Executive Director and explained the reason for the visit.

LPA Lewis gathered documentation and interviewed director, R2 was pushed to the ground in front of PCA staff by R1, R2's family was informed and called the police a report was taken. R1 refused any medical attention and was not hit or pushed. Staff intervened and separated the residents checking on both and calling the responsible parties.

Per California Code of Regulations, Title 22 No deficiencies were observed or cited during today's case management inspection.

An exit interview was held and a copy of this report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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