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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 01/22/2021
Date Signed: 01/26/2021 08:20:59 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: 71DATE:
01/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jade ParkerTIME COMPLETED:
04:00 PM
NARRATIVE
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LPA Johnson and LPM King conducted a TA visit today. During the visit, LPA and LPM observed rooms identified with proper signage including positives residents and isolated residents. The Administrator perform donning and doffing of PPE‘s as he went through each positive resident’s room. The tour confirmed that the facility continues to have issues with lack of infection control on both sides of the facility, Memory Care and Assisted Living. The observed issues included: laundry baskets without liners, trash and debris in the rooms not taken out, uncovered trash cans in positive residents rooms as well as non-positive residents room, no soap or paper towel dispensers and cloth towels hanging in positive residents bathrooms and showers. Further observations on tour included: PPE carts under stocked and cleaning supplies not labeled.

LPM King suggested that all staff become multi-taskers and complete all aspects of care including housekeeping while in the residence rooms. Other suggestion included staff reviewing a checklist in each room that identifies task to be completed prior to leaving each positive residence’s room.

At this time 50% of the facility has been infected by the coronavirus, the department will refer this matter to the APA to secure temporary management in the event that current administration becomes infected.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
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 3
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: 01/22/2021
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The current administrator is roommates with the identified designated replacement, both individuals are working 12 to 15 hour shifts.

The department is actively working with the facility to address all infection control needs. The facility will be provided with ongoing technical assistance and support. The department is currently working with multiple staffing agencies to establish 24 hour shifts including : LVNs to assist with medication administration as well as CNA‘s for care and supervision.

Based on this tele-visit and interviews with the Administrator on 1/22/2021, the facility did not report R1's positive test on 1/12/2021. The facility did reported the death of R1 on 1/19/2021. The facility has not follow the recommendation of the HAI for adding and using lidded trash cans, no touch soap/ sanitizer dispensers and labeling of disinfectant bottles.

The following deficiencies were 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: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 01/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2021
Section Cited

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HSC 1569.58(a)(2)Employee Actions: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.
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This requirement is not met as evidence by:
During interview and observation the Administrator is not following HAI and our recommendations for adding and using lidded trash cans, no touch soap/ sanitizer dispensers and labeling of disinfectant bottles.

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Type A
01/26/2021
Section Cited

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Reporting Requirements: Occurrences, such as epidemic outbreaks...or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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This requirement is not met as evidenced by:

Licensee did not submit incident reports of positive resident to licensing in a timely manner. This poses an immediate 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: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3