392700361-1-26-2021-27-AS-AJON-BXMM4K-20210126081653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 01/07/2021
Date Signed: 01/26/2021 08:17:04 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 STOCKTON		FACILITY NUMBER:	392700361
ADMINISTRATOR:	PARKER, JADE		FACILITY TYPE:	740
ADDRESS:	517 E FULTON ST		TELEPHONE:	(209) 466-2116
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	114	CENSUS: 77	DATE:	01/07/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Jade Parker		TIME COMPLETED:	11:45 AM

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 1/07/21 Licensing Program Analyst (LPA) Albert Johnson, Licensing Program Manager (LPM) Liza King, Program Clinical Consultant (PCC), Roxane Fangon, RN, BSN and Public Health Nurse Pam Costamagna conducted an announced case management visit. LPA, LPM and Nurses met with Administrator Jade Parker. During the tele-visit, caregivers were observed wearing PPE including N95 masks and face shields. Staff also performed donning and doffing of PPE before entering the red zone on the second floor of the assisted living side. The facility has posted the donning and doffing sequence signage recommended during the previous tele-visit. The CDC sequence indicates the use of hand sanitizer at each step of removing PPE if anything gets contaminated during the process. Also noted during this tele-inspection the rooms did have hand sanitizer on hand, as had been recommended during the previous tele-visit. The facility is testing at twenty five percent now. Nurse informed Administrator that all staff working in the facility should wear N95 mask, because there are positive residents in the facility. As of right now they are only allowing essential workers into the facility. They were advised to not have communal dining or group activities. Until the local health department reviews the plan.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

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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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: 01/07/2021

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Administrator stated that he does have a sufficient supply of N95's. The facility received N95's mask, gowns and gloves from the county today. Signs are located on the outside of the resident doors. There are trash can outside of the rooms that staff can dispose of used PPE. PCC Nurse recommended that trash liners be placed in the rooms of positive residents until they can purchase trash cans with lids, also recommended was that all staff handling laundry wear full PPE. PCC reviewed cleaning procedures, products and cleaning techniques.

The Department will continue tele-visits once per week. The mitigation plan will be submitted to the department by 1/24/2021 and to the local public health department. The department also provided a burn rate calculator and a staffing agency call list.

No deficiencies were observed during today’s call. Exit interview was conducted with Jade Parker where LPA reviewed report with Jade via telephone. An electronic copy of the report was emailed to the facility to obtain a signature from the Administrator and emailed back to LPA to be filed.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

LIC809 (FAS) - (06/04)

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