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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 10/10/2024
Date Signed: 10/10/2024 12:26:20 PM


Document Has Been Signed on 10/10/2024 12:26 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: 57DATE:
10/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Hansel TassinTIME COMPLETED:
12:15 PM
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On 10/10/2024, LPA Johnson arrived unannounced to complete an incident report case management follow-up visit.

The visit is to deliver findings from an investigation the department conducted to determine if there was any negligence

Based on R1's care records, she did not require a special diet. R1, at times would eat quickly so staff cut up certain food for her, like meat, to ensure she didn’t choke. On 8-10-2024, around 1100 hours, R1 ate her lunch, got up from the table, walked to the kitchen area and staff noticed her face turning red. Staff intervened, started the Heimlich and CPR after she collapsed. 911 was called. Paramedics treated R1, but ultimately, they were unable to save her, and she was pronounced dead on scene. The facility had no requirements to cut up R1's food but did it anyway to be safe. R1 never had any sort of food incidents in the past.

No further action is required. The facility provided R1 with the required duty of care.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
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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