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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700642
Report Date: 03/17/2022
Date Signed: 04/14/2022 11:00:28 AM

Document Has Been Signed on 04/14/2022 11:00 AM - 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:SOMERFORD PLACE, STOCKTON ADULT DAY CAREFACILITY NUMBER:
392700642
ADMINISTRATOR:ANDERSON, LESLIEFACILITY TYPE:
775
ADDRESS:3530 DEER PARK DRIVETELEPHONE:
(617) 796-8350
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 45CENSUS: 0DATE:
03/17/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Leslie AndersonTIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Albert Johnson arrived unannounced for a case management visit. To follow-up on clarification with the Licensee if there has been any progress in the change of ownership since the last request on 02/09/2022.

The following items are still outstanding:

INCOMPLETE DOCUMENTS:
Section A Documents:
A1. Application for Facility License (LIC 200)
-Line 6. Indicate email address.
-Resubmit complete LIC 200.

A2. Applicant Information (LIC 215)
-Check box “B” under the section titled “Business Experience” and resubmit complete form for Rick Jenson.
-Check box “B and C” under the section titled “Business Experience” and resubmit complete form for Brian Uhlir.
-Submit complete LIC 215 for Steve Kregel.

A9. Financial Information Release and Verification (LIC 404)
-Please provide a copy of the most recent bank statement for Northstar Senior Living Inc. showing liquid assets 1x the amount of Line 37 on the Monthly Operating Statement (LIC 401).

Continued
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
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 04/14/2022 11:00 AM - It Cannot Be Edited


Created By: Albert Johnson On 03/17/2022 at 01:34 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: SOMERFORD PLACE, STOCKTON ADULT DAY CARE
FACILITY NUMBER: 392700642

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2022
Section Cited
CCR
82005

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82005 License Required
Unless a day program is exempt from licensure as specified in Section 82007, Exemption from Licensure, no adult, firm, partnership, association,
corporation, county, city, public agency or other governmental entity shall operate, establish, manage, conduct or maintain an adult day program,
or hold out, advertise or represent by any means to do so, without first obtaining a current valid license from the licensing agency.
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The potential licensee will submit to the department the required information outlined in the letter sent on 2/9/22 and this regulation (82005).
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This requirement is not met as evidenced by lack of Records present to the licensing agency.
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The information will be submitted to the department by 03/18/2022.

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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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SOMERFORD PLACE, STOCKTON ADULT DAY CARE
FACILITY NUMBER: 392700642
VISIT DATE: 03/17/2022
NARRATIVE
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A10. Personnel Report (LIC 500)
-Page 2 to 5. Revise the name of the facility at the top of each form.

A13. Criminal Record Statement (LIC 508) & Criminal Record Clearance
-Submit complete LIC 508 for Steve Kregel.

1. If any individuals need an exemption transfer, they must provide an LIC 9188, LIC 508, a job description specifying their role in the facility and picture ID to the Caregiver Background Check Bureau. It can be faxed to (916) 754-4589 or emailed to webmaster@dss.ca.gov.
Other:
-RCFE- AB 601 Disclosure Information (LIC 606)
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC809 (FAS) - (06/04)
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