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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 04/08/2021
Date Signed: 05/07/2021 11:30:08 AM

Document Has Been Signed on 05/07/2021 11:30 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: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: 54DATE:
04/08/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Maria CantoriaTIME COMPLETED:
03:00 PM
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On 4/8/2021at 11:10am Licensing Program Analyst (LPA) Ashley Boothe conducted an unannounced heath and safety check with Temporary Manger (TM) and Executive Director Karen Mills (ED)Today’s census is 54 on site. LPA toured facility with TM and ED.

Observed entry, visitor policy, visitor logs. LPA entered through ringing the locked front door, sanitizing supplies and PPE were available near the sign in sheets. COVID precautions signs posted and hand sanitizer was available throughout the facility. Residents and staff observed wearing masks in communal areas. Observed PPE stations stocked and posted Donning and Doffing sequences. Extra PPE is stored in office N95 and the rest of PPE is stored separate in AL Activity office. LPA will order additional PPE supplies from Regional Office at TM’s request. Staff one (S1) stated food on hand food supply is enough. S1 provided daily menu for foods served today and stated they were leaving to purchase additional food supply and will purchase every three days. Observed communal dining in AL dining room, communal dining at lunch. Observed residents’ room 110 in AL ready per isolation protocols. Observed trash can, signage, PPE instructions, restroom, handwashing sign, paper towels, trash can, chair, nightstand, and lighting. TM requested staff to install paper towel dispenser and check all rooms for dispensers to be added. Observed communal dining in MC for snack time socially distanced. Unlocked chemical storage where staff was present filling the mop bucket. Observed MC patio area and green bus removed. Observed afternoon activities in dining room and staff in service training scheduled for 2:30pm. LPA observed staff cleaning using zep to disinfect tables in between use.

No deficiencies were cited. An exit interview was conducted with Cnatoria. A copy of this report was provided to via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Cantoria is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2021
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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