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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002682
Report Date: 10/14/2021
Date Signed: 10/14/2021 01:58:00 PM

Document Has Been Signed on 10/14/2021 01:58 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:SUNNY PLACE OF STOCKTONFACILITY NUMBER:
397002682
ADMINISTRATOR:EXPECTACIO VIERRAFACILITY TYPE:
740
ADDRESS:807 WEST SWAIN ROADTELEPHONE:
(209) 956-8677
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 18CENSUS: 13DATE:
10/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Expectacio VierraTIME COMPLETED:
02:00 PM
NARRATIVE
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 On 10/14/2021 at 1:20pm, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced case management to conduct a follow up on an incident report submitted to the Department. LPA was allowed entry into the facility, met with Administrator, and and explained the purpose of today’s visit. Census 13.

During the course of the investigation, LPA conducted interviews and reviewed records. Interviews and records review conclude Resident one (R1) moved in and on third day of admission, responsible party was advised R1 to be moved out and R1 was picked up the same day. Report stated staff are not trained to provide the appropriate level of care of R1's known behaviors prior to admission. The did not issue a 60 day eviction letter to Resident one (R1's) responsible party. Licensee did not send a 3-day eviction letter request to CCLD for approval.

Per California Code of Regulations (CCRs) - Title 22, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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Document Has Been Signed on 10/14/2021 01:58 PM - It Cannot Be Edited


Created By: Ashley Boothe On 10/14/2021 at 01:40 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: SUNNY PLACE OF STOCKTON
FACILITY NUMBER: 397002682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited
CCR
87224(a)

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Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)..notice to the resident is required except as otherwise specified in paragraph (5)
This requirement is not met as evidence by:
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Licensee agrees to submit a plan of correction to LPA by POC due date how the facility will maintain compliance with the regulation at all times.
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Based on records review and interview the licensee did not comply with the section cited above in that R1 was evicted from the facility without written notice which poses a potential health, safety, and personal rights risk to person's 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:Liza King
LICENSING EVALUATOR NAME:Ashley Boothe
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
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