392700306-10-11-2024-27-AS-KHOS-DBZLVS-20241216080600

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700306
Report Date: 10/11/2024
Date Signed: 10/11/2024 02:14:45 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
09/10/2024 and conducted by Evaluator Kesha Lewis

COMPLAINT CONTROL NUMBER: 27-AS-20240910094037

FACILITY NAME:	WAGNER HEIGHTS RESIDENTIAL		FACILITY NUMBER:	392700306
ADMINISTRATOR:	MANISHA PUNNI		FACILITY TYPE:	740
ADDRESS:	2435 WAGNER HEIGHTS RD		TELEPHONE:	(209) 477-5353
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	80	CENSUS: 72	DATE:	10/11/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	MANISHA PUNNI		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff denied resident access to medical treatment
Staff refuse to assist resident with food
Staff uses resident money

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 Staff and the R1,the allegations Staff denied resident access to medical treatment, Staff refuse to assist resident with food and
Staff uses resident money are UNSUBSTANTIATED.

Based on interviews and documents recieved R1 was sent to the hospital by the facility this was reported to the department in an SIR, Staff state they provide R1 with assistance to the dinning room and of they do not want to go staff will provided room service.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (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)

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Control Number 27-AS-20240910094037

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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R1 sigened a credit card payment form for their family member that reside in the same room at the facility for payment of rent in the amount of $530.00. 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 King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha Lewis	TELEPHONE: (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)

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