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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 10/05/2023
Date Signed: 10/05/2023 01:03:56 PM


Document Has Been Signed on 10/05/2023 01:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SUMMERFIELD OF STOCKTONFACILITY NUMBER:
392700644
ADMINISTRATOR:ANDERSON, LESLIEFACILITY TYPE:
740
ADDRESS:3530 DEER PARK DRIVETELEPHONE:
(209) 951-6500
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY:60CENSUS: 52DATE:
10/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:L. AndersonTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived at facility to conduct a Case Management visit to address the Departments investigation into multiple incidents that occurred on different days involving aggressive acts by residents on other residents. The facility was given a citation on 4/7/2023 for "Care of Persons with Dementia" and "Reappraisals."

The facility has appealed the citations given on 4/7/2023. The appeal states that the facility did not decrease their staffing levels and claims the Department’s assertion they had is untrue. The appeal states that, "Even if the facility had reduced the number of staff that regulation only states that a facility must ensure there is an adequate number of direct care staff to meet resident needs." The appeal further stated that The Department failed to establish that decreased staffing levels resulted in a resident’s death. The appeal was granted by the Department and the citations will be removed.

During the review of this matter the Department discovered that the facility employed an individual that was excluded for life on or about June 5, 2018 and that individual has been working since October 21, 2022 to last day worked August 18, 2023. This was confirmed by unemployment papers provided to Oasis P.E.O Claims by the facility for S1.

Citation given on this day for Criminal Record Clearance on the attached 809 D page.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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 10/05/2023 01:03 PM - It Cannot Be Edited

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: SUMMERFIELD OF STOCKTON
FACILITY NUMBER: 392700644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2023
Section Cited
CCR
87355(e)(1)(2)(3)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
(3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.
This requirement is not met as evidenced by: records reviewed
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The staff is no longer working at the facility. A request has been made to have S1 reinstated.
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The facility employed an individual that was excluded for life on or about June 5, 2018 and that individual has been working since October 21, 2022 to last day worked August 18, 2023.
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Civil penalty assessed

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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: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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