392700361-2-19-2021-27-AS-ABOE-BYDRDZ-20210219115645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 02/19/2021
Date Signed: 02/19/2021 11:57:21 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: 73	DATE:	02/19/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Robbie Cantoria		TIME COMPLETED:	11:00 AM

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On 2/18/2021 Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Teams at 9:30am with Temporary Manager (TM) Maria Cantoria, Designee Robbie Cantoria, and Administrator (ADM) Jade Parker. Today’s census is 73, 55 on site.

LPA reconciled the line list on 2/18/2021 and requested information for 9 residents previous documented as positive and not reported to CCLD to be submitted to the Regional Office (RO) by close of business 2/19/2021.

Facility toured to clear POC’s cited on 2/12/2021. Observed repaired MC unit door in working order.

Memory Care rooms 122 and 129 did not observe toothpaste, lotion, shampoo, body wash and mouth wash. Observed hand washing sign posted, paper towels, wall mounted soap, and covered touchless trash cans. In room 129, observed oxygen sign posted on the window. Observed staff smoking outside 10 feet away on a patio and TM stated she will put caution tape to detour staff from smoking close to the area outside the room. Observed oxygen sign posted on the outside of door.

Observed housekeeping cart with Ecolab peroxide labeled SIT time 3-5 minutes and Zep labeled SIT time 60 seconds. Designee stated last in service training for disinfection practices was on 2/17/2021. LPA requested staff sign off to be submitted to the RO by 2/19/2021. Designee stated no bleach is in use at this time.

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: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

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: 02/19/2021

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Continued from 809.

Observed staff break area in memory care with disinfect after use signs posted on tables. LPA recommended trash can with a lid and foot pedal. It was immedi

Designee stated daily activities for Memory Care today included karaoke and vibrating machine as a structured activity at 10:30am. Designee stated there is a plan in place for actives. TM stated 9:30-11 planned actives with 4 people. Observed no residents who participated in actives today, Designee stated about 30% will participate when asked.

Rooms 136 and 134 observed, hourly logs noted shower, food and water intake, and changing.

Observed Resident COVID monitoring logs completed for 2/17/2021 and 2/18/2021. Designee stated floor manager is responsible three times daily at 9am, 8pm, and once mid day.

Observed Designee redirect resident in hallway to put mask back on while in a common area.

Observed rooms 105 and 109 hourly logs error made, Designee stated he provided retraining to staffthis morning. Both were private and observed paper towels on counter not in a holder. Designee stated TM prioritized toilet paper holders as not all rooms have toilet paper holders, but he will discuss with TM to order paper towel dispensers if in the budget. LPM recommended contacting Ecolab to see if they have a program for discounted dispensers with paper towel purchase.

Observed the ceiling in the lobby has water damage, including the seams bubbling and water was reported to have leaked from the light fixture and various spots in the ceiling during the rains. A temporary fix is in place and barricades have been removed. Designee stated the rain last night was minimal and no water was observed leaking. Roofers have been to the facility to inspect and are working on quotes for repair.

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: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

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: 02/19/2021

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Continued from 809 C.

Line List reviewed. Residents are in the process of being reappraised by newly appointed Medical Director (MD), finishing today.

Resident one (R1) Observed staff in full PPE providing care, LPM recommended R1 cleared on 2/18/2021 as long as he does not have any symptoms. TM stated he has a lot of not healing wounds and staff will continue to wear PPE while providing care. Resident two (R2) is receiving 1:1 care MD will be back today to reappraise him. Resident three (R3) hospice notification SIR received by the RO on 2/19/2021. Resident four (R4) is still not compliant, MD will attempt another reappraisal today. Resident five (R5) was admitted to the ER on 2/18/2021 tested positive on 2/18/2021, asymptomatic. SIR received by the RO on 2/19/2021, no discharge plans, she will be there for 5 to 7 days, responsible

Dementia Care Plan of Operations to be submitted to the RO by 2/23/2021

Signed 809 reports to be submitted to the RO by 2/19/2021 for the reports dated 2/5/2021, 2/6/2021, 2/8/2021, and 2/10/2021

Signed 9099 report dated 2/12/2021

LIC500 including Aya staff to be submitted to the RO by 2/19/2021.

Line List updates needed to be submitted to the (RO).

· Vaccination dates for staff to be submitted to RO by 2/20/2021.

· Residents reappraisal notes to be submitted to the RO by 2/20/2021.

Residents with updated Dementia diagnosis to be submitted to the RO by 2/20/2021.

An exit interview was conducted with Cantoria. A copy of this report was provided to via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Cantoria 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: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

LIC809 (FAS) - (06/04)

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