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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002682
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:59:33 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/27/2023 04:59 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:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Larry VierraTIME COMPLETED:
05:00 PM
NARRATIVE
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On 2/27/23 at approximately 1:30pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Licensee Larry Vierra in person and with Espie Vierra by telephone.

The facility serves residents with Dementia. LPA Jensen toured the facility and grounds. The facility has a single designated entry with COVID screening protocols in place. The facility maintains a 30 day supply of PPE. The facility was determined to be adequately furnished and was observed to have sufficient lighting throughout. The fire extinguisher was last serviced in March of 2022 and is in compliance. The Ansul system was last serviced in March of 2022 and is in compliance. The carbon monoxide detector was determined to be in working order. The facility thermostat was set at 71 degrees which is within the required range of 68-85 degrees. The water temperature in a resident bathroom was measured at 118 degrees which falls within the required range of 105 to 120 degrees. All required signs were posted in areas that were easily visible by residents and staff.

The facility was observed to maintain a two day supply of perishable of food and a 7 day supply of non-perishable food. All knives were observed to be locked and inaccessible to residents in care. The dinner service being prepared accurately reflected what was posted on the dinner menu. The medication cart is kept in the dining room.

LPA Jensen reviewed 3 resident files. The Centrally Stored Medication and Destruction Record for Resident 1 had no entries for the date medication was started for a PRN Hydrocodone dating back to at least July of 2022. If the medication was started on the same date the Hydrocodone was filled then the Medication Administration Record was inaccurate. 3 of 3 resident CSMDR had missing entries for various medications and LPA Jensen was unable to determine whether the medication was accurate or not.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: SUNNY PLACE OF STOCKTON
FACILITY NUMBER: 397002682
VISIT DATE: 02/27/2023
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Continued from LIC 809C...

LPA Jensen toured the grounds and observed all pathways were clear. There is sufficient outdoor furniture for residents to participate in outdoor activities. LPA Jensen various piles of debris in the back yard of the facility including broken tupperware, paper plates, broken bed frames. discarded mattresses.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/27/2023 04:59 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: SUNNY PLACE OF STOCKTON
FACILITY NUMBER: 397002682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2023
Section Cited

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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident ... This requirement was not met as evidenced by:
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The Licensee agrees to have an outside vendor conduct training for all staff on medication that at a miinimum includes medication storage and record keeping by Plan of Correction due date. Proof of correction to be sent to maja.jensen@dss.ca.gov.
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LPA's review of the CSMDR showed no entries documented for date started for Hydrocodone since July of 2022 and amount of medication dispensed did not match records. This poses a potential risk to teh health, safety and personal rights of residents in care.
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Type B
03/27/2023
Section Cited

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Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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The Licensee agrees to remove all debris from the backyard of facility by POC due date and to send photos to maja.jensen@dss.ca.gov.
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LPA's observation of piles of debris in yard. This poses a potential risk to the health, safety and personal rights of 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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