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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700644
Report Date: 03/17/2022
Date Signed: 04/14/2022 11:12:31 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/14/2022 11:12 AM - 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 - STOCKTONFACILITY NUMBER:
392700644
ADMINISTRATOR:ANDERSON, LESLIEFACILITY TYPE:
740
ADDRESS:3530 DEER PARK DRIVETELEPHONE:
(209) 951-6500
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 60CENSUS: 45DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Leslie AndersonTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst Albert Johnson arrived unannounced to conduct an Annual inspection. LPA met with the Leslie Anderson Administrator.

LPA inspected the physical plant with including but not limited to the kitchen, bedrooms for residents, resident bathrooms, laundry area and general assembly area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 112.9 degrees Fahrenheit, which is within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications and toxins are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA that the facility is not following the Doctor's order for PRN medication administration. R1 and R2 were given PRN medication without notifying the primary care Physician, The PRN letter in both residents file request that the Primary care physician (PCP) be notified prior to giving the PRN medication. The facility did not notify the PCP for R1 or R2 prior to giving medication on multiple occasions. This information was reviewed in the residents medication administration record. LPA reviewed 10 resident and 5 staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were observed and cited during this visit. Exit interview held and a copy of report given with appeal rights at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
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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Document Has Been Signed on 04/14/2022 11:12 AM - It Cannot Be Edited


Created By: Albert Johnson On 03/17/2022 at 01:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SOMERFORD PLACE - STOCKTON
FACILITY NUMBER: 392700644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2022
Section Cited
CCR
87465(d)(1)(2)

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(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:
(1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication.(2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.
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The facility will develop a plan to meet the regulatory requirement outlined in this regulation and submit the plan to the department by POC date 3/18/2022.
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This requirement is not met as evidenced by lack of records for R1 and R2, as well as an interview with Med-Tech on duty. This poses an immediate health and safety risk to 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:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


LIC809 (FAS) - (06/04)
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