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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 06/14/2021
Date Signed: 06/15/2021 11:40:23 AM

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 - STOCKTONFACILITY NUMBER:
392700644
ADMINISTRATOR:ANDERSON, LESLIEFACILITY TYPE:
740
ADDRESS:3530 DEER PARK DRIVETELEPHONE:
(209) 951-6500
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:60CENSUS: 32DATE:
06/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lakhveer Kaur (Director of Resident Care)TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst Albert Johnson arrived unannounced to conduct an Annual inspection. LPA met with Lakhveer Kaur and explained the purpose of the visit. Later joined by Leslie Anderson Administrator.

LPA inspected the physical plant with including but not limited to the kitchen, bedrooms for residents, resident bathrooms, laundry area and general assembly area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 117.9 degrees Fahrenheit, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. However the fixed or Ansul system is out of compliance; the system was due for service on May 17 2021. LPA observed centrally stored medications and toxins are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA and Director of Resident Care observed medication for R1 without a pharmacy label as well as not being logged into the Centrally Stored medication Log. Also observed were medications for PRNs/over the counter medications for 2 of 3 residents (R2 and R3) reviewed without a label with required information. LPA reviewed resident and staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited during this visit. Exit interview held with Director of Resident Care and a copy of report given and appeal rights at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SOMERFORD PLACE - STOCKTON
FACILITY NUMBER: 392700644
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2021
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on: Observation, The facility failed to maintained in conformity with the regulations
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adopted by the State Fire Marshal. The "Fixed System" in the kitchen. This system is scheduled for a semi-annual maintenance and LPA observed that the last service was on 11/17/2020.
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 new tags as proof and submit Statement of Compliance by POC date**Fire Clearance Civil Penalty Assessed***
Type B
06/28/2021
Section Cited

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80075 Health Related Services (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication.(2)The exact dosage. (3) The minimum number of hours between doses.(4)The maximum number of doses allowed in each 24-hour period.
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This requirement was not met as evidenced by records reviewed. (R1) did not have a prescription for Novolog/ flex pen. Also observed were medications for PRNs/over the counter medications without required information. This poses a potential health and safety risk to client.
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2021
LIC809 (FAS) - (06/04)
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