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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002613
Report Date: 09/11/2024
Date Signed: 09/11/2024 02:51:34 PM


Document Has Been Signed on 09/11/2024 02:51 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 LIVINGFACILITY NUMBER:
515002613
ADMINISTRATOR:GILDEA, CHANTELFACILITY TYPE:
740
ADDRESS:1224 PLUMAS STREETTELEPHONE:
(530) 755-3850
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:99CENSUS: DATE:
09/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Chantel GildaTIME COMPLETED:
03:00 PM
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LPA Hiratsuka conducted this unannounced case management visit in response to a resident who left without assistance on August 21, 2024 and returned the same evening. LPA obtained some more information about the incident today. It does not appear the resident and staff did anything incorrect.

There are no deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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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