392700361-2-10-2021-27-AS-LKIG-BY4NY4-20210210095206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 02/06/2021
Date Signed: 02/10/2021 09:52:45 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:	DATE:	02/06/2021
TYPE OF VISIT:	Case Management - COVID-19	ANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Maria Cantero, Temporary Manager		TIME COMPLETED:	05:45 PM

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Licensing Program Manager (LPM) LIza King, Regional Manager (RM) Krystall Moore, Temporary Manager (TM) Maria Cantero and Jade Parker Administrator (ADM) participated in a conference call on this date at 3 to 3:30pm then again 4:30 to 5:30 to discuss the implementation of the TM in the facility effective today as a result of the continued concerns related to COVID-19 and the facilities practices.

Documentation requested prior to call today Updated Linelist and most recent HAI report neither received. According to ADM he has not received the most recent HAI report. ADM reported Current census 66 (MC23, AL43)

Mass testing 02/04/2021 resulted in 5 positives reported today (20 results of approx. 60) No staff positive reported today. SIRs received/ all identifying information confirmed and reported on a separate 812.

Staffing is not a concern, ADM stated that there was no longer a need for 4 Aya staff. LPM explained that Aya is on a 30 day contract. Aya staffing 4 on NOC last night and 0 on am. Reports on staffing are currently made daily to LPM by ADM prior to noon via text. No schedule arranged for aya staff at this point, confirmed LPM confirmed with ADM that a schedule needs to be implemented. This was discussed earlier in the week with ADM as well. Cornerstone staffing is currently providing 1 LVN 6pm to 6am.

Staffing implemented as a result of TMs involvement include 2 MedTechs, 3 caregivers, 2additional caregivers and 1 MT coming in from out of town in the upcoming days. LPM requested updated LIC500. NO current need for an LVN per TM, Infection Control will focus will be at this time Infection Perventionalist (IP) to start Monday. Contract w Vitas for infection control training who provided a link for infection control training to be completed before end of week by all staff.

TM will have skin issues reassess throughout the evening. Updates will be reported on linelist.

Todays discussion focused on the Overview of previous HAI recommendations which include:

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

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: 02/06/2021

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· Recommend the facility contact …non-emergency transport company in the region willing to transport COVID-19 residents to outpatient dialysis centers. --ADM reported the facility is working with PROtransport and AM West. Transportation is no longer an issue. According there was only resident that was having difficulty recieving transport (prev SIR submitted)

· Consider placing a screening table at the facility entrance.... 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). --TM reported a form has been created and a screening table to being implemented.

· Remind staff (and visitors) to wear masks when on facility property. During this outbreak, it is recommended all staff universally wear NIOSH approved N95 disposable respirator and face shield (or goggles) at all times, and removed ONLY when actually eating or drinking to minimize the risk of worker transmission. Return to wearing procedure masks for source control once the facility has achieved negative results in two rounds of response testing for staff and residents, or other local health department criteria for defining the termination of the current outbreak. --According to TM signage is being added, all staff are wearing N95 masks and will wear face shields. LPM will provide reuse instructions for N95.

· Recommend the facility closely monitor breakrooms, nursing stations, common and patio areas.__ ADM reported signage is in place on break tables. every shift before and after shift cleaning will occur (staff enters building is screened and then goes to their workstation and disinfects). Currently using alcohol wipes and a product w 3 minutes SIT time, this was discussed in the staff meeting today, staff will be carrying the spray bottles that have identified product and sit time. This new process will be implemented by tomorrow.

· At breakrooms, post signs on doors stating occupancy limits and remove excess furniture…Place disinfectant wipes and alcohol-based hand rub (ABHR) on each table. Use laminated signs instructing staff to clean and disinfect common surfaces before and after use. Again, post signs to remind staff that face PPE is to remain on at all times and removed ONLY when actually eating/ drinking. --ADM reported Extra chairs in MC dining room for break area have been removed no extra chair were in AL breakroom, procedure is on the tables, wipes and all staff are aware of procedure..

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

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: 02/06/2021

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• At designated smoking areas, frequently monitor residents and include in the area in the facility cleaning and disinfection plan. Ensure staff/ residents maintain a distance greater than six feet and perform hand hygiene before and after smoking. --ADM reported that hand sanitizer is avail at smoking area and 2nd smoking area has been set up, all chairs have been removed, signage has been posted for one resident at a time.
• Recommend the facility continue practices and maintain postings regarding hand hygiene, cleaning and disinfection, masking, and distancing throughout the remaining pandemic, occasionally changing the presentation of the signage to attract attention. –TM reports that she has brought signage and will review the practices of the building. TM has hung new laminated signage.
• Recommend the facility monitor temperature and pulse oximetry of each residents and screen each resident for symptoms consistent with COVID-19 illness at minimum once per shift. Increase monitoring frequency to every 4 hours for suspected and positive COVID-19 residents. Recommend 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. --ADM reported All residents are being monitored every 4 hours with a 12 hour gap while they are sleeping.
• …Recommend the facility procure an EPA registered surface cleaner and disinfectant with a contact time of three minutes or less to limit the need to reapply... Ensure all staff are competent in appropriate cleaning and disinfecting practices, including disinfection of cleaning equipment (e.g. mop handles, dusters, etc.) before returning to the cart. Validate by monitoring staff adherence on a regular basis. Use a checklist to assure compliance with the facility daily disinfection plan. Recommend the facility instruct staff to bundle care tasks to conserve PPE and limit number of entries into isolation rooms. Include disinfection of high touch surfaces in rooms as part of the care tasks. This frees housekeeping to clean and disinfect common areas in hallways, nursing stations, and breakrooms more frequently. Train staff on disinfectants, application methods, and contact times (wet times) to ensure staff adhere to facility infection control practices.--ADM started that housekeepers have a checklist. There will be a lead staff that will be monitoring / QA whom was identified in todays meeting. A checklist will be made for caregivers for disinfecting and cleaning. Caregivers are now universal workers and will be carrying a disinfectant solution with them, disinfecting the resident rooms, emptying garbage and pulling laundry to the laundry area.
· It is recommended the facility contract with registry, and in the interim, train staff in appropriate cleaning and disinfecting practices and encourage staff to take responsibility for cleaning and disinfection when time allows. Ensure disinfectants are readily available for staff use. --TM reported Training will be provided tomorrow on disinfecting.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

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: 02/06/2021

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· Recommend the facility fit test all staff as soon as possible for the safety of staff and residents. As a reminder, fit testing is specific to the make and model of the mask. If the staff member does not have the option of wearing the mask they were fit-tested to, then they must be fit-tested to a new mask (Also, refer to line 19). ADM reported that he has purchased the FIT testing kits, but has not contacted Concerta LPM will send the PIN. There is a MT that is training to become a fit tester. LPA to follow up.

· Recommend inventory be counted routinely and at least as frequently as once per week to determine usage rates to project need for ordering replacements to maintain supplies to last at current usage rates for 1-3 months. TM and ADM did an inventory the facility is inneed of N95 and surgical masks. Need large gloves, need gowns, need n95 (picked up on Tues this week) requesting ADM states that he has asked the licensee and has been spending his own money. TM will order PPE.

· Recommend the facility place PPE stations equipped with gowns, gloves (various sizes), ABHR, and trash can at each isolation room entrance. The station can be any container, cart, or table that can store PPE and be cleaned and disinfected. Recommend the facility develop a system to ensure PPE station supplies are inventoried and stocked on each cart each shift. ADM stated that they will implement a plan to monitor the PPE stations.

Additional information reported included LPM to contact ALW program and coordinate visits. According to ADM book keeper quit this week as did the front office.

LPM confirmed daily calls to occur at 2pm daily. Covid vaccines to occur on Monday Feb 8th.TA will be tentatively scheduled for Monday at 2pm may postpone to Tues based on vaccine schedule.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

LIC809 (FAS) - (06/04)

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