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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 03/05/2024
Date Signed: 03/05/2024 03:08:24 PM


Document Has Been Signed on 03/05/2024 03:08 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: 60DATE:
03/05/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rosalie SullivanTIME COMPLETED:
03:00 PM
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On 3/05/24 Licensing Program Analyst (LPA) Kesha Lewis arived unannounced to conducted a case management for the purpose of verifying that S1 who was served an Individual of Immediate Exclusion from all facilities was not currently working at the facility. LPA Lewis met with Rosalie Sullivan, LPA explained the purpose of today's visit. Staff (S-1) excluded as a result not related to this facility.

LPA Lewis verified the facility received the letter of exclusion and took copies of the letter of discharge for S1, S1 has not been at the facility since 03/07/2023.

No citations were issued on today's date. A copy of the report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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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