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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 10/02/2020
Date Signed: 10/02/2020 03:31:04 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 STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:PARKER, JADEFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 81DATE:
10/02/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Jade Parker, Administrator TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Diego Escobar 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 10/02/2020 and this LPA was able to speak with the facility designated Acting Administrator, Jade Parker, who was briefly interviewed and explained the purpose of the call. Current census was 79 residents.

On August 4, 2020, LPM Liza King made three attempts throughout the day to contact the facility to confirm they had no COVID-19 positive residents or staff. Upon calling the facility, the facility recorded information was provided, then an option of extensions. The LPM entered various extensions, and with each the call was redirected to a voice mail box that was full and not receiving any new messages. At 3:30pm, the LPM spoke with Eleina Ridolfi, the Administrator who confirmed that the facility telephone was not accepting incoming calls on a regular basis, and that she had contacted the phone company on 07/31/2020 to resolve the issue. However, was told that due to COVID there is a backlog of work orders. No follow up had been completed. The LPM suggested to the Administrator to have the phones forwarded to a cell phone which could be left at the community to be answered by staff. The Administrator replied, “that’s a good idea”. The Administrator also stated that she made sure the voicemails were cleared out. The LPM asked the Administrator to contact the designee in the facility at this time (3:52pm) and ask that person to contact the LPM, to verify the phones can dial out. At 4:30pm on 08/04/2020, the LPM received a call from S1 the designee of the facility. S1 reported that he had left the facility for the day and was calling the LPM from his cell phone. S1 reported that the phone system at the facility has been experiencing problems receiving calls since last week. When LPM asked him if it was since Friday, S1 reported he was unsure the exact day but followed up with an email to the phone company just now. LPM asked S1 to contact the facility and ask a staff on site to please contact LPM. At 4:42pm, a conference call was held between S2, LPM King, RM Krystall Moore. The facility staff who reported being present at the facility and called from the listed facility phone number. After discussion, S2 agreed that the calls do not always go through to the facility.
CONTINUES ON LIC 809-C
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020
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: 10/02/2020
NARRATIVE
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During this same time period a conference call was conducted between the LPM and the RM, calling the facility main phone number and the nurse’s extension. S3 answered the call and confirmed that not all phone calls to the facility go through and that families have made complaints about this.


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 additional civil penalties. Appeal rights were provided. Exit interview conducted with Jade Parker. Copy of the report sent to Jade via e-mail with a "read receipt" to verify the LIC 809, LIC 809-D, LIC 811 and appeal rights were received. Jade is to print out the LIC 809 and LIC 809-D, and fax signed copies to LPA at 916-263-4744.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020
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: 10/02/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2020
Section Cited

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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14)To have reasonable access to telephones, to both make and receive confidential calls...
This requirement has not been met as evidenced by:
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Based on observation, and interview, licensee did not comply with the regulation cited above as the phone system is inoperable, which poses a personal rights violation to the 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: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3