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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700306
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:30:52 PM


Document Has Been Signed on 04/26/2024 03:30 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: 65DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:MANISHA PUNNITIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Continuation Visit. LPA was met by administrator. LPA explained the purpose of the visit.

LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 80 bed facility with a current census of 65. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool.

Hot water temperature was measured at 109 F degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
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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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
VISIT DATE: 04/26/2024
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The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point.

Exit interview and copy of report given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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