Summerfield of Stockton

Type of visit: Required - 1 Year

On 2-19-2026 at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Leslie Anderson and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen areas, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an residential care facility for the elderly (RCFE) with a current census of 49. Facility has 60 bedrooms and 60 bathrooms for resident use. Facility has dining rooms and additional common areas for resident use. LPA also conducted the inspection using the CARE tool. Facility also currently provides care for 8 hospice, and 0 bedridden. The facility has an approved infection control plan in place. Water temperature reads 105*F to 120*F in the bathrooms and room temperature reads 72*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 2-12-26. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed and contained accompanying regulatory required Physician’s orders. First aid kit was observed to have adequate supplies and accessible to staff. {Cont. on 809C} During this inspection 5 resident files and 5 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. All staff noted on LIC 500 contained criminal background clearances. LPA completed 3 resident interviews and 3 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. Facility does not contain any bodies of water. LPA observed personal rights and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 308 and LIC 500. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administratorthe state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Case Management - Incident

On 2-19-2026, Licensing Program Analyst (LPA) Michael Bilger conducted a case management visit regarding a self reported incident. LPA met with Administrator Leslie Anderson and explained the purpose of the visit. LPA conducted brief interview with Administrator, staff2(S2) and resident1 (R1). LPA also reviewed incident report with Administrator. Based on incident report dated 2-17-2026, a staff member on 2-16-2026 at approximately 7:42am heard a “thump noise” and resident1 (R1) yelling. Staff member checked on R1 and observed R1 lying on right side of bedroom door. Resident was awake and alert, and complained of pain to her head and right arm. Staff initiated call to 911 timely and R1 was taken to hospital for evaluation. R1 returned back to facility same day. A scan was performed at the hospital which was noted as “clear” with no new orders. A review of incident report noted “injury cause by another resident.” Based on further review and interviews, it was determined that R1 experienced an unwitnessed fall with no evidence of another resident causing the fall or injury. As a result of this case management, no citations are issued. An exit interview was conducted and copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Feb 19, 2026

Allegation investigated: Staff did not ensure resident was properly treated for scabies Staff did not seek timely medical care for resident Staff are not ensuring residents hygiene needs are met

Allegations: Staff did not ensure resident was properly treated for scabies/ Staff did not seek timely medical care for resident Based on records reviewed the facility was made aware in June of 2025 that R1 was having some type of skin irritation and the facility contacted the family. R1's family made an appointment with R1's primary care physician (pcp) who looked at R1's skin and prescribed topical medication (No skin test). On July 10th of 2025, the facility requested and held a video appointment with R1's pcp, because R1 was not getting better. R1's pcp ordered a second round of topical medication. Unsubstantiated On August 15th of 2025, R1 was taken to an appointment for swelling of face and eyes and received a diagnosis of an adverse reaction to medication and not Scabies. R1 never received a diagnosis of Scabies. The facility provide R1 with medical care on several occasions and attempted to address the alleged scabies outbreak for R1. Allegation: Staff are not ensuring residents hygiene needs are met. LPA was able to review assistance of daily living schedule for showering, toileting, dressing and meal reminders and confirmed that the action items on the services were being documented, however, the department is not able to confirm by observation that all action items were completed daily or weekly. The complaint is Unsubstantiated.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 27-AS-20250912144135

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Albert Johnson arrived at facility to conduct a Case Management visit due to a possible outbreak of scabies. Based on records reviewed residents in care are being treated by their primary care physician's with medication and topical ointment. The department has requested that the facility provide a line list of the residents that are being treated. The department has also requested that the facility contact public health to get guidance on mitigation for control of this potential outbreak. This information is expected to be email or faxed by close of business on 9/5/2025. No deficiencies cited. Advisories given for hygiene items being accessible and breathing treatment equipment maintenance. Exit interview conducted.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson arrived at the facility unannounced to complete a health, safety, and welfare visit of the clients in care. LPA met with Staff and explained the reason for the inspection. LPA reviewed 5 incident reports received 2 out of 5 incident reports were reported late. LPA also reviewed facility’s fall prevention program and conducted interviews with the nurse and Administrator. LPA also conducted a review of discharge plans for the 5 residents and observed that the facility has made arrangements for the review of the service plans with responsible parties for those residents returning. Additionally during review of incident report, it was determined that 2 of 14 incident reports were submitted to regional office beyond seven days of occurrence and not within reporting requirement regulations. As a result of today’s visit, advisories were given. .the state’s words, verbatim · CDSS document, Jun 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst Albert Johnson arrived unannounced to conduct an Annual inspection. Currently 54 clients reside at the assisted living facility (all dementia). Facility has a fire clearance granted for 60 non-ambulatory residents with up to 12 receiving hospice services. 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 and clean. The facility has a fire door located in the Ivy cottage that is in need of replacement and a heater booster for the dishwasher in the main kitchen that needs fixing. Advisory given. 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 110.9 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. Fire drill was conducted on 1/2025 as required. LPA observed centrally stored medications and toxins are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 12 resident and 6 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, No citations given. Exit interview held and a copy of report given with appeal rightthe state’s words, verbatim · CDSS document, Mar 18, 2025

Type of visit: Case Management - Incident

On 10/10/2024, LPA Johnson arrived unannounced to complete an incident report case management follow-up visit. The visit is to deliver findings from an investigation the department conducted to determine if there was any negligence Based on R1's care records, she did not require a special diet. R1, at times would eat quickly so staff cut up certain food for her, like meat, to ensure she didn’t choke. On 8-10-2024, around 1100 hours, R1 ate her lunch, got up from the table, walked to the kitchen area and staff noticed her face turning red. Staff intervened, started the Heimlich and CPR after she collapsed. 911 was called. Paramedics treated R1, but ultimately, they were unable to save her, and she was pronounced dead on scene. The facility had no requirements to cut up R1's food but did it anyway to be safe. R1 never had any sort of food incidents in the past. No further action is required. The facility provided R1 with the required duty of care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson arrived at the facility unannounced to complete a health, safety, and welfare visit of the clients in care. LPA met with Staff and explained the reason for the inspection. LPA toured the facility, confirm the signs posted in the dining area and obtain statements for staff providing service to R1 on 8/10/2024. LPA inspected the physical plant, inside and out. Facility is maintained at a comfortable temperature. Residents in care appeared to be safe and have no imminent health/safety concerns observed. As a result of this inspection, No deficiencies were cited. Exit interview conductedthe state’s words, verbatim · CDSS document, Aug 16, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident. LPA reviewed special incident report dated 8/12/2024 stating R1 choked on food from lunch. R1 did not recover from the incident. R1 passed away. R1 physician's report dated 6/12/2023 and 7/31/2024 confirmed that there were no food restrictions or special diets. The facility was provided with a police report number and was also given a Corner's report number with a badge number. The department has copies of both. During today's visit, LPA reviewed and obtained copies of R1's file, medical records related to the incident, service plan, and the food menu for the day. No citation issued today. Exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 13, 2024

Allegation investigated: Resident assaulted another resident resulting in questionable death.

On 8/2024, LPA Albert Johnson arrived unannounced to deliver findings for the above allegation. The department investigated whether staff neglect resulted in the altercation between the two residents, which resulted in the death of the victim, The department does not have the evidence to support that the facility failed to adequately supervise the residents resulting in the altercation. Based on the department's report, this was an isolated incident between the two residents. There were no prior incident reports of the perpetrator being physically or verbally aggressive with anyone that would have prompted facility staff to provide increased supervision to him. Additionally, two staff were present at the time of the incident. The complaint is Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 2, 2024 · control 27-AS-20240605114621

Type of visit: Case Management - Incident

Licensing Program Analyst Albert Johnson conducted an unannounced case management visit to the facility to follow up on an incident. LPA reviewed special incident report dated 4/27/2024 stating R1 had an unwitnessed fall and as a result sustained a fractured hip. R1 has a history of falls and the facility has taken precautions to minimize R1 from falling. R1 has an updated service from 3/20/2024 based on the assessment R1 was independent with transferring. After the fall and ER visit on 4/27/2024, R1 was discharged to a skilled facility for rehabilitation and will be assessed to return on 5/15/2024. R1 moved in on or about 12/20/2021 without any durable medical equipment. During today's visit, LPA reviewed R1's file, medical records related to the fall and service plan which is dated 3/20/2024. Exit interview was conducted with Staff.the state’s words, verbatim · CDSS document, May 14, 2024

Type of visit: Case Management - Other

On 5/1/2024, Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced Case Management visit today at the facility. LPA was following -up on multiple incident involving the Stockton fire department. During visit LPA Johnson reviewed records for dates of service and interviewed the Administrator and Resident Services Director about events related to call for assistance with residents in care. The facility provided incident reports for falls when the resident were sent out for evaluation. Also, included were times when the responsible party for the resident refused emergency services. The facility did not submit incident report for lift assist, because residents were not sent out to be evaluated. The facility will schedule a meeting with the local fire district to develop a plan to address the on-going need to lift assist with some residents. The facility will contact the department with the outcome of the meeting. The information will be submitted to the department by the close of business on 5/8/2024. No deficiencies were cited during this visit. Exit interview heldthe state’s words, verbatim · CDSS document, May 1, 2024

Type of visit: Required - 1 Year

On 3/7/2024, Licensing Program Analyst Albert Johnson arrived unannounced to conduct an Annual inspection. Currently 53 clients reside at the assisted living facility (all dementia). Facility has a fire clearance granted for 60 non-ambulatory residents with up to 10 receiving hospice services. 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 118.9 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. 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, no citations. Exit interview held and a copy of report given with appeal rightthe state’s words, verbatim · CDSS document, Mar 7, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Albert Johnson arrived at facility to conduct a Case Management visit to address the Departments investigation into multiple incidents that occurred on different days involving aggressive acts by residents on other residents. The facility was given a citation on 4/7/2023 for "Care of Persons with Dementia" and "Reappraisals." The facility has appealed the citations given on 4/7/2023. The appeal states that the facility did not decrease their staffing levels and claims the Department’s assertion they had is untrue. The appeal states that, "Even if the facility had reduced the number of staff that regulation only states that a facility must ensure there is an adequate number of direct care staff to meet resident needs." The appeal further stated that The Department failed to establish that decreased staffing levels resulted in a resident’s death. The appeal was granted by the Department and the citations will be removed. During the review of this matter the Department discovered that the facility employed an individual that was excluded for life on or about June 5, 2018 and that individual has been working since October 21, 2022 to last day worked August 18, 2023. This was confirmed by unemployment papers provided to Oasis P.E.O Claims by the facility for S1. Citation given on this day for Criminal Record Clearance on the attached 809 D page.the state’s words, verbatim · CDSS document, Oct 5, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1)(2)(3) · Plan of correction due date: Oct 6, 2023

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by: records reviewed The facility employed an individual that was excluded for life on or about June 5, 2018 and that individual has been working since October 21, 2022 to last day worked August 18, 2023.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: The staff is no longer working at the facility. A request has been made to have S1 reinstated. Civil penalty assessed