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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 11/23/2021
Date Signed: 11/24/2021 07:15:53 AM

Document Has Been Signed on 11/24/2021 07:15 AM - 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:SOMERFORD PLACE - STOCKTONFACILITY NUMBER:
392700644
ADMINISTRATOR:ANDERSON, LESLIEFACILITY TYPE:
740
ADDRESS:3530 DEER PARK DRIVETELEPHONE:
(209) 951-6500
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 60CENSUS: 39DATE:
11/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Joseph Amantia and Liz Kaur TIME COMPLETED:
04:15 PM
NARRATIVE
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LPA Albert Johnson arrived unannounced for a case management visit. The reason for the visit was to clarify with the Licensee if there have been any changes in ownership since the license was opened 3/6/2020 and to confirm who has current control of property, when the residents were notified of any changes and if there was a change to the management company.

Business Office Manager confirmed that the facilities' management responsibilities were taken over on 10/1/2021 by Northstar Senior Living and that the control of property is with SNH CAL TENANT LLC.

LPA was able to make contact with Regional Vice President of Operation Evelyn Mendez -Choy and Brook Lothwer Operation and Marketing Specialist via telephone. LPA requested a copy of agreement as the management company for this facility, Contact for (CDSS) California Department of Social Services Central Application Bureau, Resident notification letter regarding the change in management companies.

The facility has changed it's name to Summerfield of Stockton Memory Care. This was confirmed by LPA's observation and review of new resident move-in checklist and facilities' brochure with a "New RCFE license Pending number 397001229" and the sign on the front of the building.

Continued
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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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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:
FACILITY NUMBER:
VISIT DATE: 11/23/2021
NARRATIVE
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Also discussed was who the current LIC 308 (DESIGNATION OF FACILITY RESPONSIBILITY) is for the facility when the assigned Administrator of record is not at the facility.

Based on this visit the Sacramento Adult and Senior Care Regional Office is requesting a meeting with you to discuss the operation of this licensed facilities. Your attendance at this meeting is mandatory.

A tele-conference meeting has been scheduled for:

Monday, November 29, 2021 at 1:30 PM.

Contact information will be provided on Monday 11/29/2021.

There are deficiencies being issued today.

Exit interview conducted and a copy of this report provided to Business Office Manager on-site along with appeal rights.

Additionally this report was sent via email to: Regional Vice President of Operation Evelyn Mendez -Choy and Operation and Marketing Specialist Brook Lothwer.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2021 07:15 AM - It Cannot Be Edited


Created By: Albert Johnson On 11/23/2021 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SOMERFORD PLACE - STOCKTON
FACILITY NUMBER: 392700644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2021
Section Cited

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(a) Any person seeking a license for a residential care facility for the elderly under this chapter shall file with the department, pursuant to regulations, an application on forms furnished by the department, that shall include, but not be limited to, all of the following:(3) If applicable, the following information:
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(F) The name and address of any management company serving the facility and the same information required of applicants in subparagraphs (C) and (D) for the management company. This requirement is not met based on observation and records reviewed.
This poses an immediate risk to residents in care.
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Contact for the Central Application Bureau that has been working with the facility on this update to the license by 11/24/2021
Type A
12/03/2021
Section Cited

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(h) Any change in the chief corporate officer of an organization, corporation or association shall be reported to the licensing agency in writing within fifteen (15) working days following such change. Such notification shall include the name, address, and the fingerprint card of the new chief executive officer, as required by Section 87355, Criminal Record Clearance.
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This requirements was not met based on lack of records to review and interviews conducted.
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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 Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021


LIC809 (FAS) - (06/04)
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