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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 02/05/2021
Date Signed: 02/10/2021 08:39:17 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: 74DATE:
02/05/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Jade ParkerTIME COMPLETED:
06:30 PM
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Licensing Program Analyst (LPA) Johnson and Licensing Program Manager (LPM) Doub conducted a TA visit to review the assessment from Healthcare-Associated Infections (HAI) from California Department of Public Health and address on-going concerns with infection control at the facility.

The HAI has been out to the facility twice, during the first visit on 1/13/2021 the facility was given a list of recommendations including screening processes; recommend placing a stand at the immediate entrance with signage stating hand hygiene must be performed each time the building is entered; recommend amending the screening form to include all symptoms recognized by the Center for Disease Control and Prevention (CDC); all staff wear masks when on facility property. During this outbreak, it is recommended all staff universally always wear NIOSH approved N95 disposable respirator and face shield (or goggles) and removed ONLY when eating or drinking. It was also recommended creating a written process and procedure for reporting changes in condition.

The policy and procedure should include monitoring frequency based on COVID status, acceptable ranges, and reporting chain of command. There are other recommendations included in the report to mitigate the spread of the virus in the community.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
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 5
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: 02/05/2021
NARRATIVE
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The Department conducted a tele-visit on 1/22/2021 with Administrator Jade Parker and noted several deficiencies as a result of that tele-visit. Those deficiencies included 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. The Facility /Administrator was not following HAI and our recommendations from the 1/13/2021 assessment for adding and using lidded trash cans, no touch soap/ sanitizer dispensers and labeling of disinfectant bottles. The facility also received a citation for failing to report incidents related to positive COVID residents.

The Department conducted another tele-visit on 1/29/2021 with Andrew Corpuz. The facility Administrator was out picking up PPEs. During the visit, LPA Johnson and LPM King observed rooms identified with proper signage including positives residents and isolated residents. The facility staff (Andrew) perform donning and doffing of PPEs 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 resident’s rooms as well as non-positive residents’ room, no soap or paper towel dispensers and cloth towels hanging in positive residents’ bathrooms and showers.

The facilities' most recent follow-up assessment on 2/4/2021 from HAI detail more of the same concerns addressed in the initial assessment.

Continued

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 02/05/2021
NARRATIVE
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 HAI voiced concern because there’s a lot of movement around the facility with some residents wearing mask and some not, some staff wearing masks and some not. HAI's officials also mention that on the first visit all staff were wearing mask and gloves etc. however on the follow-up visit not all staff were wearing their mask correctly.

HAI assessment on 2/4/2021 included an immediate concern with the front door unlocked and there was no screening and a review of the screening the logs showed that it was not updated and there was no social distancing. Additionally, the HAI had major concerns with the PCR test turnaround time, as well as fit testing for all staff, and training concerns for food preparation/handling for designated responsible person Xavier. Xavier is the Maintenance Director who is responsible for cooking, client care and maintenance issues as they arise.

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

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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 02/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2021
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 Facility/ Administrator is not following HAI and our the departments recommendations for mitigation protcols including enforcing mask wearing, screening and documentation at the entrance.
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Type B
02/08/2021
Section Cited

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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This requirement was not been met as evidenced by: LPM King and LPA Johnson observed bathrooms with no hand soap or paper towels in multiple bathrooms This is an immediate safety risk to the clients
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 02/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2021
Section Cited

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87405 Administrator-Qualifications and Duties:(d) The administrator shall have the qualifications specified in Sections 87405...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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This requirement is not met as evidenced by: Based on interviews and file reviews The Administrator failed to follow HAI recommendations and supervision policies for social distancing. This posed an immediate health and safety risk to residents in care.
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Type B
02/10/2021
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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This requirement is not met as evidenced by: Based on record review and interviews, the staff did not wear mask according to state mandates which 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5