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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
515002613
Report Date:
09/20/2023
Date Signed:
09/20/2023 02:04:15 PM
Document Has Been Signed on
09/20/2023 02:04 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SUMMERFIELD SENIOR LIVING
FACILITY NUMBER:
515002613
ADMINISTRATOR:
GILDEA, CHANTEL
FACILITY TYPE:
740
ADDRESS:
1224 PLUMAS STREET
TELEPHONE:
(530) 755-3850
CITY:
YUBA CITY
STATE:
CA
ZIP CODE:
95991
CAPACITY:
99
CENSUS:
64
DATE:
09/20/2023
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
01:00 PM
MET WITH:
Chantel Gildea, Gayle Rounds, and Rebecca Ballantine
TIME COMPLETED:
02:15 PM
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LPA Hiratsuka conducted this unannounced case management in response to several incident reports submitted by this facility.
LPA interviewed the Wellness Directors for both memory care and assisted living. LPA was also able to speak to Executive Director. LPA was able to clarify the incidents and the content of what may be on the incident reports.
No deficiencies cited.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4700
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
09/20/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/20/2023
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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