392700361-2-8-2021-27-AS-ABOE-BY366X-20210208193239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 02/08/2021
Date Signed: 02/08/2021 07:37:41 PM

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: 74	DATE:	02/08/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jade Parker and Maria Cantoria		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Ashley Boothe. Licensing Program Manager (LPM) Liza King, and Regional Manager (RM) Krystall Moore conducted an announced case management visit via Teams at 2pm with Temporary Manager (TM) Maria Cantoria and Administrator (ADM) Jade Parker.

TM stated records are incomplete and TM and ADM are working on updating records to reflect accurate information. Reported today census is 74. As of today there are 48 (9 AL and 6 MC active positive cases) positive of which 26 are cleared and 7 deaths. 17 staff are positive of which 13 have and 0 deaths. TM stated the five residents tested positive over the weekend are doing well but one is non compliant, ripping the signs off the door. Three residents in the hospital, one COVID related, no discharge plans as of yet. 7 residents are in Skilled Nursing are there are no discharge plans for any residents. Line list briefly reviewed, information is missing for multiple resident entries and testing data.

LPA requested ADM to update and submit current line list to the Regional Office on 2/9/2021 including condition of residents and dates when they were transferred to hospital or skilled nursing facility.

TM stated medical technicians are monitoring residents at least twice daily during medication pass and more often with additional medication passes. Positive residents are monitored 4 times daily. One positive resident is combative and another resident is refusing hygiene assistance.

Currently designated staff are not in place to care to positive residents. TM stated 10 of her team supporting facility operations and no staff from Aya have shown up to the facility as of today's call. Some staff members have stopped showing up for work and ADM and TM if they still want to work there.

LPM requested ADM submit an updated LIC500 to the Regional Office on 2/9/2021.

Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

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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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: 02/08/2021

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Continued from 809.

ADM stated he received communication to fill out administrator association paperwork for another facility and plans to starting working there next Monday through Friday. TM stated the daily calls scheduled at 2pm conflict with the stand up meeting. LPM will reschedule and send an updated meeting invitation to notify of the time change. The meeting was concluded as TM left to conduct a staff meeting.

An exit interview was conducted with Jade. A copy of this report and appeal rights were provided to via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Jade 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.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

LIC809 (FAS) - (06/04)

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