392700361-7-25-2022-27-AS-MBIR-CGNU7D-20220725151947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 07/25/2022
Date Signed: 07/25/2022 03:22:32 PM

Document Has Been Signed on 07/25/2022 03:22 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:	STACIE'S CHALET STOCKTON		FACILITY NUMBER:	392700361
ADMINISTRATOR:	ANURADHA SAINI		FACILITY TYPE:	740
ADDRESS:	517 E FULTON ST		TELEPHONE:	(209) 910-5910
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	0	CENSUS: 0	DATE:	07/25/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Facility Closed: Report mailed to previous licensee		TIME COMPLETED:	03:19 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7-25-22 at 1:23pm, Licensing Program Analyst (LPA) conducted a case management based on additional information received in relation to complaint #27-AS-20220121111716. The allegations based on this complaint number for purposes of this case management were: Dental hygiene not provided and foot care not provided to resident1 (R1). Complaint was completed on 6-28-22. On 7-1-22, additional evidence was received by complainant regarding foot and dental hygiene allegation as noted above. The evidence received was dated 11-15-2018 and 11-19-2018. LPA reviewed evidence which included documented and audible conversations regarding dental and foot care for resident1 (R1). Allegation: Dental hygiene not provided Based on a documented conversation on 11-15-2018 Staff1 (S1) and responsible person for R1, it is indicated that R1 saw a dentist on 3/30/2017 for a tooth extraction. On 11-19-2018 the dental appointment on 3-30-2017 was confirmed through another documented conversation with S2. Based on this conversation, responsible party was attempting to work with facility's assistance to have R1 evaluated by a dentist since 3-30-2017. Additionally, based on this conversation, there were no further appointments scheduled or indicated for follow up by facility. Based on an additional documented conversation on 11-19-2018 between responsible person and conservator for R1, conservator took R1 to the dentist on 11-18-2018 at which time it was recommended R1 full upper and lower dentures, and all teeth had major cavities. Based on evidence reviewed, it is determined that facility knew or should have known of dental hygiene and related needs as a result, and so informed responsible party for appropriate intervention. {Cont. on 809C}

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

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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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: 07/25/2022

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Allegation: Foot care not provided. Based on the additional evidence received on 7-1-2022, on 11-15-2018, a documented conversation between R1's responsible person and S1 occurred. Based on this conversation, responsible person was attempting to have R1's toenails evaluated due to concern for in-grown toenail. Review of this evidence revealed R1 did not have a podiatry consult appointment arranged as of 11-15-2018. Furthermore, this evidence revealed that S1 was unable to assess further as only the nurse on duty had access to a list for residents to be seen by podiatrist. Evidence additionally indicates nurse was on leave at the time of this conversation between responsible person and S1 with no date of return given by S1. This conversation ultimately resulted in S1 stating R1 will be placed on podiatry list in December of 2018 with no date of when R1 will be seen.

On 11-19-2018 a documented conversation between R1's responsible person and S2. Based on LPA's review of this additional evidence, it was revealed that S2 was told of R1's "in grown toenails" by R1's responsible person, but S2 was unaware of R1's foot condition. Furthermore, S2 was unsure if R1 was placed on the list for podiatry visit within facility. Additionally, based on evidence provided, responsible party for R1 inquired about outside podiatry appointments and told by S2 that podiatrist is from bay area, and facility's driver doesn't go to bay area. Based on evidence reviewed, it is determined that facility knew or should have known of R1's foot condition and so informed responsible party for appropriate intervention.

Based on the evidence reviewed, citations are issued under Title 22, Division 6. Facility has since closed. A copy of this report was mailed to previous licensee with a request for return with signature. Appeal rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/25/2022 03:22 PM - It Cannot Be Edited

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: 07/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/02/2022 Section Cited	1 2 3 4 5 6 7	Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on evidence reviewed, licensee did not ensure appropriate and timely dental care and hygiene for R1 after learning of dental care needs. This posed a potential health and safety risk to resident care	8 9 10 11 12 13 14
Type B 08/02/2022 Section Cited	1 2 3 4 5 6 7	Incidental Medical and Dental care.(a)A plan for incidental medical...care shall be developed by each facility. The plan shall encourage routine medical care... and provide for assistance in obtaining such care...: (2)The licensee shall provide assistance in meeting necessary medical needs. This includes transportation...In providing transportation the licensee shall do so directly or make arrangements for this service.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on evidence reviewed, licensee did not ensure podiatry care visits in or outside facility timely for R1 through appointments and transportation resulting in inadequate foot care provided. This poses a potential health and safety risk for resident.	8 9 10 11 12 13 14

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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