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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 01/06/2021
Date Signed: 01/07/2021 08:42:18 AM

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: 88DATE:
01/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Jade ParkerTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson contacted the facility to conclude a case management visit via telephone due to COVID-19 and pre-cautionary measures. A telephone call made to this facility on 1/06/2021 and this LPA was able to speak with the facility designated Administrator, Jade Parker. Current census was 79 residents.

LPM King conducted an announced TA of the facility with the RCD Joel on 1/5/2021 as a result of reported COVID positive residents. PER THE TA VISIT: Currently census originally reported, AL 47 residents of which “6 or 7 are positive” and MC census 28 with “6 positive”. Front door doors are locked w/ proper signage. Entry area includes no touch sanitizer (2) in lobby area, temp check and questions for staff and/or hospice home health screening provided by designated staff, then staff are asked to go wash their hands. Screening of staff occurs upon entry into the building. Observation of the screening logs occurred. Health Care Providers sign into one book, get screened on another form then enter their contact number on a report at the end of their visit. No PPE provided in this area. Staff come in wearing their own cloth masks and health care providers donn their own PPE prior to entering the facility.

Cont.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
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 6
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: 01/06/2021
NARRATIVE
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AL COVID WING –When asked if there are designated staff working the COVID area, Joel responded that there are only 2 staff working in all of the Assisted Living and 2 staff working in the Memory Care. When asked what the normal staffing is like, he responded it is usually 3 on each staff but they are short staffed all the time and staff are afraid to work with COVID residents. Joel proceeded into the COVID area, when asked where the PPE station is, he responded it is supposed to be there (already in the COVID wing through the fire doors). When asked if he was going to donn PPE he responded he had to return to his office to get PPE. Phone call terminated for 5 minutes while he did so. Call resumed with him in his office, LPM observed him donning PPE then returning to the COVID wing (16 rooms total) When asked how many residents in this area are positive and how many rooms were ready for additional positives, Joel explained that there are 6 or 7 positive residents in the area, the rest are negative and refused to move. Some doors had signage that say ISOLATION with the resident’s name, date tested and date cleared, but other rooms have no identifying signage, and when asked Joel was unsure if rooms without the signage were positive or negative. Therefore we only entered into the rooms designated as positive, since there were no PPE stations in the area, PPE was not changed between positive rooms. Entry into R1 room the exterior of the door stated that resident is to be isolated until 01/01/21, yet resident remains in COVID area. R1 bathroom contained no hand soap or paper towels, no trashcan and no signage in BR. R2 room stated isolation until 01/06/2021, no soap or paper towels in bathroom, no trash can. Residents soiled clothes were in a pile next to the unlined partially fill laundry basket, resident complained of not feeling well, aches, sore throat, cough, having diarrhea and soiling her clothes. When asked about laundry Joel responded that staff bag it and take it to the laundry room.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: 01/06/2021
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R3 No sign on door however Joel reported resident was positive, so we entered. No soap, no paper towels, hoyer lift and soiled clothes on the floor. Med Tech takes the temps 3 xday LPM recommended every 4 hour temperature checks. Residents are screened daily for symptoms and temp is taken 3xday by the Med Tech, when LPM asked if this was documented Joel stated if it is not already he could implement it.

Exiting COVID area, the nearest location after Joel left the area to doff his PPE was in a public restroom which seemed to be 3 doors past the COVID wing after exiting the area. Soap and paper towels were present as well as a uncovered trashcan. MEMORY CARE: staff observed throughout area wearing cloth face masks and face shields. No specific area for COVID residents all residents are to remain in their rooms. Inconsistencies with identifying signage on the door as was seen in the AL COVID wing. Some doors identify “Isolation” Some doors state must wear PPE and other doors do not identify any precautions but were identified as positive rooms. One PPE station was identified in the dinning area where staff donn and doff their PPE. Staff walk throughout the Memory care area with soiled PPE, to return to the clean PPE station to doff in a noncovered trash can. In the residents rooms, personal care supplies were observed throughout. 2 of 4 residents had mounted hand sanitizer in their room. Paper towels were not present nor were gloves in the rooms. R1 restroom had personal care supplies to include shampoo and mouthwash, he has a roommate but roommate has been in SNF since Oct. R2 room had peri-wash and cream and antibacterial skin care in a container near the sink. This resident was seated on a bed with no sheets, no blankets, no pillows only an egg create. R3 no signage on the exterior of the door, hand sanitizer no towels, R4 no soap no paper towels, periwash and toilet paper located on coffee table.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: 01/06/2021
NARRATIVE
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LPM reminded Joel that a residents 602 states whether or not a resident is to have access to personal care supplies, and if the resident resides in the memory care than other residents that are not to have access need to be safe guarded from hazardous materials such as personal care supplies. Joel was in agreement and aware. LPM asked Joel how staff know if a resident is positive, Joel responded that a manger calls each staff member. LPM asked if there was a stand up meeting conducted, a shift change meeting or a communication log for staff to communicate with one another, Joel responded there was not. LPM observed Joel entering into various residents rooms not switching PPE. For Memory Care food is brought to back door and left for staff to bring into area.

All residents are isolated, no activities occurring and reportedly have not occurred for a long time. No zoom or facetime calls being made, when asked. All residents are eating in their rooms. Various Styrofoam cups and paper/wax bowels were observed in residents rooms throughout. Activity Coordinator is currently out ill (non-Covid related).

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Jade Parker. Copy of the report sent to Jade Parker via e-mail with a "read receipt" to verify the LIC 809 and appeal rights were received. Jade Parker is to print out the report, sign it, and email a signed copy to LPA

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: 01/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities(a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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This requirement is not met as evidenced by: LPM observed Staff wearing cloth and Staff going from positive rooms to other positive rooms without changing PPE while providing care and supervision to residents which poses an immediate risk to residents in care.
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PPE Stations through out the facility. POC due date of 1/7/2021.
Type A
01/07/2021
Section Cited

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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This requirement was not been met as evidenced by: LPM observed R1 bathroom contained no hand soap or paper towels, no trash can and no signage in BR. R2 room stated isolation until 01/06/2021, no soap or paper towels in bathroom, no trash can. Residents soiled clothes were in a pile next to the unlined partially fill laundry basket, This is an immediate safety risk to the clients
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Manager shall review the Buildings and Grounds regulation and submit proof to CCL that this regulation has been met.
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: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6
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: 01/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2021
Section Cited

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87219(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers.
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This requirement is not met as evidenced by LPM interview and observation All residents are isolated, no activities occurring and reportedly have not occurred for a long time. No zoom or facetime calls being made, when asked. All residents are eating in their rooms. Various Styrofoam cups and paper/wax bowels were observed in residents rooms throughout. Activity Coordinator is currently out ill (non-Covid related). This poses a potential health and safety risk
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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: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2021
LIC809 (FAS) - (06/04)
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