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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 01/05/2022
Date Signed: 01/05/2022 04:47:19 PM

Document Has Been Signed on 01/05/2022 04:47 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:WAGNER HEIGHTS RESIDENTIALFACILITY NUMBER:
392700306
ADMINISTRATOR:COLLINS, KATRICEFACILITY TYPE:
740
ADDRESS:2435 WAGNER HEIGHTS RDTELEPHONE:
(209) 477-5353
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 80CENSUS: 59DATE:
01/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Gurpreet RaiTIME COMPLETED:
05:00 PM
NARRATIVE
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On 1-5-22 at 3:40pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to complaint #27-AS-20211228102036. LPA met with Administrator Gurpreet Rai and explained the purpose of the visit. During room observation in room #26 regarding a complaint allegation, LPA observed bathroom laminate flooring separating near toilet area. LPA witnessed floor being lifted and not secured.

Based on today's visit, deficiencies are cited under Title 22, Division 6, Chapter 8. An exit interview was conducted with Gurpreet Rai and a copy of this report was left with Gurpreet. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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 01/05/2022 04:47 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/05/2022 at 04:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: WAGNER HEIGHTS RESIDENTIAL
FACILITY NUMBER: 392700306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2022
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Licensee will repair flooring in room #26 and send photo proof to LPA by POC due date.

LPA to conduct POC visit as necessary to verify repairs.

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Based on LPA observation on 1-5-22, flooring in bathroom of room #26 was seperated and not secured near the toilet area. This poses a potential health and safety risk to resdients in care.
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Licensee will audit facility rooms to ensure any necessary repairs are addressed and completed. Licensee to submit completed audit to LPA by POC due date.

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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 King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2022


LIC809 (FAS) - (06/04)
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