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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 02/10/2021
Date Signed: 02/11/2021 01:10:27 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: DATE:
02/10/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jade ParkerTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Manager (LPM) LIza King, Temporary Manager (TMM) Maria Cantero, Jade Parker Administrator (ADM), and Robbie Canterio, Temporary Designee (TMD) participated in a conference call on this date at 2:15pm to 2:45 then again 4:00 to 5:15 (LPA Ashley Boothe participated in the 4-5:15 call) to discuss the continued concerns related to COVID-19 and the facilities practices.

LPM observed the entry area to include the point of entry, the front door was locke(appropriate signage posted). At the screening table upon entry sat a designated staff person who screened staff and visitor incl. temp and COVID related questions. A clean and dirty side of the table was observed, a ppe station incl. wipes, sanitizer, N95 masks, face shields, gloves and gowns. Behind and to the right of the screening table sat another table with staff training sign in sheets for the PM shift scheduled training. LPM requested all training logs for 02/09/2021 to be emailed.

Walking the hall of the facility words the first public bathroom, the LPM observed a trash can with lid, in the bathroom the appropriate signage was posted, wall mounted towels, soap.

In the hall, the LPM observed a second PPE station (stocked), LPM recommended that the PPE stations have an inventory list and that the drawers be labeled.

Wall mounted Hand sanitizer in the area of Room 1 observed to have liquid in it. Entry into room 1 (AL) at 2:25pm. In the bathroom was a bottle of yellow Lysol sat on the counter next to the sink. No staff were present, administrator removed the bottle of Lysol. LPM requested residents 602 to determine if resident should have access to a cleaning chemical.

SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021
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: 02/10/2021
NARRATIVE
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Entry into room 2 (AL) shared room two residents both in bed with half bedrails up at 2:30pm. Leaned against the wall was a twin sized mattress and box springs, LPM asked that it be removed upon reinspection at 4:15 both the mattress and box springs had been removed. There was oxygen in the room, no signage was present this was not corrected prior end of TA. LPM observed periwash on top of dresser in bedroom. Lpm observed toilet paper all over bathroom counters and floor, a staff member reported that this resident does this all the time. LPM observed the closet area with clothing all over closet floor. LPM asked if this resident removes clothing from hangers and puts on floor, admin was unsure. Staff reported that the resident was recently admitted to hospice. LPM requested 602 for each resident and hospice verification. Luofa in shower observed during both visits to room, TMD requested staff to remove. No liner in hamper.

LPM observed a cleaning cart and staff member in a room. When LPM asked what the staff member was using to disinfect the bathroom, the staff member went to the cart, opened the door and exposed several bottles. When asked again which one was used for disinfecting the staff member showed a bottle labeled “bleach and water”, another bottle labeled “SIT Time 15m” and another bottle with a pink solution. In the cart ther were several other bottles of solutions that the staff member was moving about, when the LPM stated that enough information was gathered. LPM spoke with TMD and admin about training of staff regarding disinfecting and limiting the number of cleaning solutions that staff are using to decrease confusion. Staff at this time are not able to clearly identify the disinfecting procedures, nor was the LPM able to verify that a disinfecting solution with a SIT time of 3 min or less as recommended by HAI is being used.

At 4:20 upon entry into MC area, door is broken as reported yesterday. According to Admin today there are quotes being received. LPM recommended a magnetic alarm be placed on door to alert staff if the door is opened. The current practice is to have a staff member sitting next to the door monitoring, however later in the tour there was no one seated in front of the door, and the door was unsupervised. Upon a table near the MC door was a PPE station and visitor sign in sheet. Upon review a ALW nurse signed into the MC as a visitor today. LPM requested the visitor screening log for today to be sent via email. PPE station was stocked, no labels or inventory present. TMD stated that he has assigned a staff member to print labels and label drawers. 4:25 Room 3 Crest toothpastes, deodorant and aftershave present in residents sliding cabinet beneath bathroom mirror. ADM asked staff for the key to unlock the locked bathroom cabinet to place the items in a secured area. LPM recommended that additional keys be made for the locked bathroom cabinets so that the ADMIN does not have to ask staff each time a cabinet needs to be unlocked.

4:30 Room 4 No concerns.

4:35 Room 5 Shared room shampoo and bodywash observed on the kitchenette counter and body lotion present on nightstand. ADM asked staff to remove items.

SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021
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: 02/10/2021
NARRATIVE
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4:40 positive resident room 4. LPM observed Administrator donn and doff PPE before entry and upon exit of COVID positive room. Admin entered into room, resident was sitting on a bed that was a bare mattress, upon the other wall was a bed with sheets and a disheveled blanket. LPM asked for other bed to be made. LPM observed two nightstands and one dresser one nightstand and one dresser were turned so that the drawers were facing the wall, LPM requested that the furniture be placed the correct way. ADM reported that resident removes drawers. All drawers were empty. No TV, radio or other form of stimulation present in room. Resident is ambulatory, barefoot moving about the room following the ADM. LPM asked the ADM what the residents does to stay busy or what he had enjoyed in the past, ADM was unsure. LPM requested a TV or radio to provide stimulation. Mouthwash was present on the kitchenette counter, ADM removed when asked by LPM. Missing cabinet door under sink. Observation of the closet area no concerns. ADM exited the room. When asked how often resident was checked ADM reported 3 times a day, when LPM repeated the question and the previous response the ADM reported 4 med passes and 3 meals a day. A staff then reported that the residents are checked every hour, which is documented on a log. LPM observed the logs, the log does not track times. Staff and ADM were unable to clearly identify how often residents are monitored.

5:00 Observation of the large refrigerator in the MC dining room, LPM observed a red jello like substance, which was unlabeled. The refrigerator also contained several partial gallons on milk, two containers of Treetop Allpe juice, individually packaged apple sauce and multiple squeeze bottles of mustard and ketchup. ADM reported that this was a staff refrigerator.

5:10 observation of the main lobby area included area on the ceiling which appeared water damaged, bubbling in areas and a along what appeared to be seams of the ceiling. ADM reported that water was leaking from the ceiling after last weeks rain storm, water was dripping from ceiling light fixture and dripping down the wall areas. ADM reported that estimates have been made for repairs and that he is waiting on the licensees approval for repairs to be made.

Deficiencies were observed and given persuant to Title 22 rules and regulations, Health and Safety codes. Exit interview was conducted with Robbie TMD, copy of report provided via email due to COVID 19 precautionary measures, with a read receipt to verify the 809 was received. The TMD is to print out a copy of the report, sign and email back to LPA Ashley.Boothe@dss.ca.gov, appeals rights provided.

SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2021
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.This requirement is not met as evidenced by
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Based on observation and interview the LPM observed a mattress and box spiring against the wall of a memory care residents room, toothepaste, lotion, shampoo, bodywwash and mouth wash were observed in memory care residents rooms, were observed in a shared residents bathroom all of which pose an immediate health and safety risk to resients in care.
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Type B
02/19/2021
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.

This regulation was not met:
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Based on observation and interview there are currently no planned activites for residents in care, residents are isolated in their rooms with no cognitive stimulation and or no planned stimulation. Memory care resients are provided no strucutred activity or stimulation.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2021
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: 02/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2021
Section Cited

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87618 (b)(3)(B) Oxygen Administration - Gas and Liquid - Oxygen in Use signs shall be posted in appropriate areas.
This regulation was not met
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Based on observation and interview the Administrator did not post oxygen in use signs of the resident(s) rooms that had oxygen.
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Type A
02/12/2021
Section Cited

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80087(a) - 80087 Building and Grounds (a) The facility should be clean, safe and sanitary and in good repair at all times for the safety and well being of the clients, employees and visitors.

This regulation was not met
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Bsed on obseravation and interview the ceiling in the lobby has water damage, includeing the seams bubbeling and water was reported to have leaked from the light fixture and various spots in the ceiling during the rains last week.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2021
LIC809 (FAS) - (06/04)
Page: 5 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: 02/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2021
Section Cited

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87411(a) Personnel Requirements - General -(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs
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Based on observation and interview the facility staff were unable to articulate or explain clearly how often COVID positive residents are monitored. This poses an immediate health and safety risk to these residents.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6