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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 10/11/2024
Date Signed: 10/11/2024 01:22:18 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2024 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20240709145039
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: 72DATE:
10/11/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:MANISHA PUNNITIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident sustained unexplained fracture while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver findings for the allegations. LPA was greeted by Executive Director and explained the reason for the visit.

Based on the information gathered, from records reviewd and interviews with hospital staff and facility staff the allegations that a resident sustained unexplained fracture while in care is UNSUBSTANTIATED.

Dameron Hospital medical records revealed that resident 1 (R1) was diagnosed with a displaced fracture of the head of the proximal phalanx (her pinky finger) of the fifth digit on 6/20/2024. R1 was unable to disclose how they sustained the injury. Several staff had consistent statements of not knowing how R1 sustained the injury.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20240709145039
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/11/2024
NARRATIVE
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 Doctor Mohammad Al Hasan stated R1 could have fractured their finger by being transported, falling, or hitting their finger on a wall. Note that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was held and a copy of this report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2