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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
392700644
Report Date:
06/14/2021
Date Signed:
02/16/2022 12:09:55 PM
Document Has Been Signed on
02/16/2022 12:09 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:
SOMERFORD PLACE - STOCKTON
FACILITY NUMBER:
392700644
ADMINISTRATOR:
ANDERSON, LESLIE
FACILITY TYPE:
740
ADDRESS:
3530 DEER PARK DRIVE
TELEPHONE:
(209) 951-6500
CITY:
STOCKTON
STATE:
CA
ZIP CODE:
95219
CAPACITY:
60
CENSUS:
34
DATE:
06/14/2021
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
09:53 AM
MET WITH:
Liz Kaur
TIME COMPLETED:
10:15 AM
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The Post licensing visit was completed.
LPA reviewed staff and residents records the records were complete.
No deficiencies for the post licensing visit.
SUPERVISORS NAME
:
Stephenie Doub
LICENSING EVALUATOR NAME
:
Albert Johnson
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/14/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/14/2021
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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