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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 09/03/2020
Date Signed: 09/03/2020 04:18:27 PM

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:STACIE'S CHALET STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:PARKER, JADEFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 79DATE:
09/03/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jade Parker, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Diego Escobar and Ashley Boothe conducted an unannounced Case Management visit on 9/3/2020 at 10:30 AM to conduct a health and safety check visit. During the visit, LPA met with, Jade Parker, Administrator, and stated the purpose of the visit.

LPAs toured the facility kitchen with Jade. LPAs observed at least one week of non-perishable foods and two days of perishable foods. LPAs obtained copies of itemized list of foods deliver to the facility every week.
LPAs and Administrator toured the rooms of three residents (R1, R2, and R3) that receive home health services. LPA's reviewed the files of R1, R2 and R3. R1 is diagnosed with dementia and has a medical assessment dated 4/14/19. Administrator confirmed there was no updated medical assessment for R1.

LPAs observed R4 waiting for an ambulance to transport her to the hospital for wound care for a large, red, swollen tear discharging puss on the front of R4's right shin. LPA observed Jade look through R4's chart and question staff. R4 was released from the hospital on 8/23/2020 with physician's instructions to "have your facility check the wound daily" and to follow up with primary care provider within 1 to 3 days. Staff 1 (S1) confirmed no follow up was done with R4's primary care provider. The Activities Daily Living Flow sheet is signed by a caregiver from 8/23/2020 to 9/2/2020 "Skin Integrity check (note areas of concern on progress notes) has been signed off with no additional notes on the status of the wound. S1 stated that they have not been assisting in changing her bandage.

LPA's reviewed the facility's narcotic medication logs for memory care residents. Administrator stated, R5's narcotic medication, Alprazolam, was destroyed with S2 on 9/1/2020. LPAs asked for medication destruction records. Centrally stored medication and destruction record (CSMDR) was provided to LPAs. CSMDR is missing expiration date, date filled, date started, and name of pharmacy upon intake of the medication.
CONTINUES ON LIC 809-C
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: STACIE'S CHALET STOCKTON
FACILITY NUMBER: 392700361
VISIT DATE: 09/03/2020
NARRATIVE
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The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Jade Parker.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: STACIE'S CHALET STOCKTON
FACILITY NUMBER: 392700361
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2020
Section Cited

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(e) In addition to Sections 87465(a) and 87464(d) the licensee shall ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met.
This requirement has not been met as evidenced by:
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Based on interview and observation with Administrator and S1 the Licensee did not follow or document R4's physician's orders which poses a potential health and safety risk to residents in care.
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Type B
09/11/2020
Section Cited

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(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458.
This requirement has not been met as evidenced by:
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Based on record review the Licensee did not obtain an updated medical assessment for R1. R1's last completed assessment was on 4/14/2019 which poses a potential 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: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: STACIE'S CHALET STOCKTON
FACILITY NUMBER: 392700361
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2020
Section Cited

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(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(A) The name of the resident for whom prescribed.
(B) The name of the prescribing physician.
(C) The drug name, strength and quantity.
(D) The date filled.
(E) The prescription number and the name of the issuing pharmacy.
(F) Instructions, if any, regarding control and custody of the medication.
This requirement has not been met as evidenced by:
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Based on interview and record review with Administrator the Licensee did not comply with the regulation cited above which poses a potential 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: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4