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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 07/02/2024
Date Signed: 07/02/2024 02:49:11 PM


Document Has Been Signed on 07/02/2024 02:49 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: 69DATE:
07/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:MANISHA PUNNITIME COMPLETED:
03:00 PM
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On 07/02/24, 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 signed for all days from May to July. Last round of incident reports was sent 06/21/2024.

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: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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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