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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:07:05 PM


Document Has Been Signed on 08/13/2024 03:07 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: DATE:
08/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:14 PM
MET WITH:L. AndersonTIME COMPLETED:
03:15 PM
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Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident.

LPA reviewed special incident report dated 8/12/2024 stating R1 choked on food from lunch. R1 did not recover from the incident. R1 passed away. R1 physician's report dated 6/12/2023 and 7/31/2024 confirmed that there were no food restrictions or special diets.

The facility was provided with a police report number and was also given a Corner's report number with a badge number. The department has copies of both.

During today's visit, LPA reviewed and obtained copies of R1's file, medical records related to the incident, service plan, and the food menu for the day.

No citation issued today.

Exit interview was conducted.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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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