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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 03/17/2022
Date Signed: 04/14/2022 11:09:06 AM


Document Has Been Signed on 04/14/2022 11:09 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: 45DATE:
03/17/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:44 AM
MET WITH:Leslie AndersonTIME COMPLETED:
01:00 PM
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LPA Albert Johnson arrived unannounced for a case management visit. To follow-up on clarification with the Licensee if there has been any progress in the change of ownership since the last request on 11/24/2021 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.

During the inspection on 11/23/2021 LPA Johnson requested to the department the required information outlined in this regulation 87211(a)(h).
(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.

The information was to be submitted to the department by 12/03/2021. LPA Johnson has not received this information as of this date 3/17/2022. The repeat citation will be included on the attached 809D page.

Continued.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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: SOMERFORD PLACE - STOCKTON
FACILITY NUMBER: 392700644
VISIT DATE: 03/17/2022
NARRATIVE
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The facility was to submit documents to the Department on February 27, 2022 and to this date the facility/licensee et.al. have not provided the requested information.

As of today March 17, 2022 the following items are still outstanding:

Section A Documents:
A4. Administrative Organization (LIC 309)
· Resubmit LIC309 – box 8, include percentages of ownership.
A7. Monthly Operating Budget (LIC 401)
· Resubmit LIC401 – line 7, revise Food Costs, should be at minimum $200 per resident. Resubmit LIC401 – line 27, include monthly rent.

A9. Financial Information Release and Verification
·Submit – Northstar Senior Living, Inc bank statement, from within the past 60-days, to demonstrate one month’s operating costs (line 37 of LIC401).

A10. Personnel Report (LIC 500) Resubmit LIC500 – specify days of shifts.

A13. Criminal Record Statement (LIC 508) Submit LIC508 – for Leslie.

Section B Supportive Documents:
B1. Partnership Agreement/Articles of Incorporation/Articles of Organization
·Submit – Articles of Incorporation (from Secretary of State) for Northstar Senior Living, Inc.
Other: RCFE Disclosure Worksheet (LIC606) – submit.
·COVID 19 Mitigation Plan (LIC 808) – submit (Licensee may have one on file; can submit).Driver’s License – submit, for Leslie, to complete facility association.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2022 11:09 AM - 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: SOMERFORD PLACE - STOCKTON
FACILITY NUMBER: 392700644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2022
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. This poses an immediate health and safety concern for residents in care.
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: SOMERFORD PLACE - STOCKTON
FACILITY NUMBER: 392700644
VISIT DATE: 03/17/2022
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Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited during this visit. Exit interview held and a copy of report given and appeal rights at the conclusion of the visit.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC809 (FAS) - (06/04)
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