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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 01/10/2024
Date Signed: 01/10/2024 01:44:57 PM


Document Has Been Signed on 01/10/2024 01:44 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 59DATE:
01/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:MANISHA PUNNITIME COMPLETED:
12:30 PM
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On 01/10/24, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator and explained the purpose of the visit.
LPA reviewed

1. Maintenance logs

2. Medication log sheets

3. Updated AWOL procedures

4. Recent incident reports

5. Random resident medical assessments

6. Training records

7. Facility observation to ensure compliance and safety

Based on random records review of resident files services plans are updated and MAR'S are singed, the Medication room narcotics log was missing 3 signatures for the month of January, for 01/01/2024, 01/07/2024. There has been a great deal of improvement in documentation regarding records at the facility.

Exit interview conducted. Copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
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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Document Has Been Signed on 01/10/2024 01:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
87465

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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility… (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on medication and to include, but not be limited to: Medication documentation signing. Proof of completed training to be submitted to LPA by POC due date.
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Based on record review, the Medication room narcotics log was missing 3 signatures for the month of January, for 01/01/2024, 01/07/2024. this posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
LIC809 (FAS) - (06/04)
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