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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:31:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/12/2023 01:31 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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: 45DATE:
01/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Joseph Amantia and Hansel TaasinTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst Albert Johnson arrived unannounced to conduct an Annual inspection.

LPA inspected the physical plant with including but not limited to the kitchen, bedrooms for residents, resident bathrooms, laundry area and general assembly area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 118.9 degrees Fahrenheit, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications and toxins are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 10 resident and 5 staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. During the resident's file review, LPA observed that the service plans are not signed by the responsible parties or the residents for 10 of 10 files reviewed.

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 with 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: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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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Document Has Been Signed on 01/12/2023 01:31 PM - 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: SUMMERFIELD OF STOCKTON
FACILITY NUMBER: 392700644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited

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The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
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The facility wiil follow the guidelines for "Resident Participation in Decision Making" and have signed service plans for all residents in care.
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This requirement was not met as evidenced by missing signatures on all (10 of 10) service plans for R1 thru R10 reviewed. This poses a potential safety risk to residents in care
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The facility will complete this by POC date 1/26/2023. The Adminstrator will provide the department with the 10 signatures after meeting with the families to the department.

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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: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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