392700644-4-9-2023-27-AS-AJON-CQR643-20230409202804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 04/07/2023
Date Signed: 04/09/2023 08:28:30 PM

Document Has Been Signed on 04/09/2023 08:28 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 STOCKTON		FACILITY NUMBER:	392700644
ADMINISTRATOR:	ANDERSON, LESLIE		FACILITY TYPE:	740
ADDRESS:	3530 DEER PARK DRIVE		TELEPHONE:	(209) 951-6500
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95219
CAPACITY:	60	CENSUS: 48	DATE:	04/07/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Liz Kaur		TIME COMPLETED:	02:23 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Albert Johnson arrived at facility to conduct a Case Management visit due to multiple incidents involving aggressive acts resulting in a death, aggressive acts resulting in a resident hitting another with a fire extinguisher. Based on records reviewed and incidents which resulted in a death and bodily injury, the department is requesting that the facility increase the staffing to address the lack of supervision which has resulted in these unfortunate incidents including a death. LPA was able to determine that the facility has reduced the number of staff on the AM shift from eight staff to seven staff and the same for the PM shift from eight to seven. The NOC shift was staffed at four and now staffed at three. As a result of this reduction in staffing the facility has compromised the safety of the residents in care. On 2/13/2023 R1 was assaulted by R2 resulting in R1 going to the ER for evaluation. The discharge summary diagnosed "Assault and back Pain. R1 has since moved out of the facility. Continued

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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 04/09/2023 08:28 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: 04/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 04/08/2023 Section Cited CCR 87705(b)(1-2)(c)(4)	1 2 3 4 5 6 7	(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4)There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.	1 2 3 4 5 6 7	Licensee will schedule an in-service training to include the complete regulation 87705, additionally the facility will added additional staff to ensure resident safety.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by incidents of aggression resulting in death and injury and lack of updated service plans for R2 and R4. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Licensee to send copy of in-service training to CCL after it's completed to clear deficiency. Civil penalties assessed
Deficiency Dismissed Type B 04/21/2023 Section Cited CCR87463(c)	1 2 3 4 5 6 7	The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.	1 2 3 4 5 6 7	The facility wiil follow the guidelines for "Resident Participation in Decision Making" and have signed service plans for all residents in care.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by review of current records for R1 and R4. also missing signatures for R5's assessment. This poses a potential safety risk to residents in care	8 9 10 11 12 13 14	The facility will complete this by POC date 4/21/2023. The Adminstrator will provide the department with the signatures after meeting with the families.

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	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

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: SUMMERFIELD OF STOCKTON	FACILITY NUMBER: 392700644
	VISIT DATE: 04/07/2023

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The service plan for R2 has not been updated to address the assaultive behavior.

On 3/4/2023 R3 was assaulted by R4 resulting in R3 going to the ER for evaluation. R3 was placed on comfort care, due to a brain bleed and stroke. R3 passed away in the hospital. The service plan for R4 has not been updated to address the assaultive behavior.

Both incidents were reported to the Stockton Police department and a Report of Suspected Dependant Adult /Elder Abuse report was submitted as required.

Per California Code of Regulations, Title 22, the following deficiencies and immediate civil penalty have been issued. The circumstances of these incidents are being evaluated for additional civil penalties. Exit interview.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023

LIC809 (FAS) - (06/04)

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