<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002682
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:08:01 PM


Document Has Been Signed on 04/11/2023 04:08 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: 12DATE:
04/11/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Expectacion VierraTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/11/23 at approximately 2:30 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a quarterly visit. LPA Jensen met with Licensee and explained the purpose of today's visit.

LPA Jensen toured the facility grounds and physical plant. The grounds were observed to be free of debris and all paths were clear. The facility was observed to be sanitary. The thermostat was set at 73 degrees which falls within the required regulatory range of 68-85 degrees. The bathroom water temperature was measured at 117 degrees and is within the required regulatory range of 105-120 degrees. The fire extinguishers and Ansul system was last serviced in March of 2023 and is in compliance.

There were three care staff providers, an administrative clerk, two Administrators and a cook on duty when LPA Jensen arrived. LPA Jensen interacted with several residents and observed that all had there needs met. Staffing levels were observed to be sufficient based on a census of 12.

LPA Jensen reviewed the training records for staff present at the time of the visit. LPA Jensen reviewed training records for inservice training done on the following dates:
3/16/23 Narcotics and PRN Medication
3/23/23 Aspiration, Dysphagia, Bedsore Prevention, Pain Management
3/30/23 Medication, Care Plans, How to contact PACE

LPA Jensen observed 2 days worth of perishable food and 7 days non-perishable food. LPA Jensen reviewed the facility food menu which listed stuffed peppers, Rice Pilaf and Brussel Sprouts listed on the menu. LPA Jensen interviewed a care provider (S1) who advised that lunch service consisted of Ravioli, Cauliflower and Bread.
Continued on LIC 809C....


SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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: 04/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC 809...

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 provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/11/2023 04:08 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2023
Section Cited

1
2
3
4
5
6
7
In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agrees to conduct an in-service training with staff and will revise future menus to include alternatives based on resident choice. Licensee will email proof of in-service training by plan of correction due date.
8
9
10
11
12
13
14
Based on LPA's review of the current menu and an interview with staff, the lunch served on this day did not reflect what was listed on the menu which poses a potential risk to health, safety and personal rights of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3