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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 05/01/2024
Date Signed: 05/06/2024 04:40:49 PM


Document Has Been Signed on 05/06/2024 04:40 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 56DATE:
05/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:L. AndersonTIME COMPLETED:
03:30 PM
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On 5/1/2024, Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management visit today at the facility. LPA was following -up on multiple incident involving the Stockton fire department.

During visit LPA Johnson reviewed records for dates of service and interviewed the Administrator and Resident Services Director about events related to call for assistance with residents in care. The facility provided incident reports for falls when the resident were sent out for evaluation. Also, included were times when the responsible party for the resident refused emergency services. The facility did not submit incident report for lift assist, because residents were not sent out to be evaluated.

The facility will schedule a meeting with the local fire district to develop a plan to address the on-going need to lift assist with some residents. The facility will contact the department with the outcome of the meeting. The information will be submitted to the department by the close of business on 5/8/2024.

No deficiencies were cited during this visit.


Exit interview held
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024
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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