392700361-2-17-2021-27-AS-ABOE-BYC6FY-20210217194703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 02/17/2021
Date Signed: 02/17/2021 07:47:51 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 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:	02/17/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Maria Cantoria		TIME COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Ashley Boothe, Licensing Program Manager (LPM) Liza King, and Regional Manager (RM) Krystall Moore conducted an announced case management visit via Teams at 3pm with Temporary Manager (TM) Maria Cantoria, Designee Robbie Cantoria, and Administrator (ADM) Jade Parker. Today’s census is 73, 55 on site. As of today there are 48 (2 AL and 1 MC active positive cases on site, 2 hospital and 2 in SNF) positive of which 26 are cleared and 7 deaths.

PPE requested on 2/16/2021 was shipped from the Regional Office including medium and large gloves. ADM was observed going to pick up PPE from MOHAC during the call today. ADM stated West Coast and Fire Company cleaning, disinfection, and decontamination completed today.

COVD testing of 17 residents on 2/17/2021, results pending. Updated Line List reflects updated testing results from 2/11/2021. LPA requested updated staff testing on Line List to be submitted to the RO on 2/18/2021.

On 2/17/2021 LPM emailed an update on when each staffing support contract ends between 2/27/2021 to 3/15/2021 and recommended to plan for a staffing plan prior to their departure. ADM stated he will follow up on applications received.

Line List reviewed. Residents were in the process of being reappraised by newly appointed Medical Director (MD). Resident one R1, COVID positive is put on Hospice 2/12/2021 is in decline, care plan updated on 2/17/2021 and Hospice Nurse was there today for wound care. Resident two (R2) is receiving 1:1 care to redirect aggressive behaviors towards furniture, staff, and residents, MD is updating LIC602 on 2/17/2021 and he had 1:1 care while residents were moved out of his room during disinfection. Resident three (R3) is showing skin integrity problem, refusing repositioning every two hours, MD will assess for Hospice today in his room, an update will be provided to the RO tomorrow. Resident four (R4) is still non compliant. Resident five (R5) and Resident six (R6) no changes in condition noted and ADM stated they will come off quarantine after tomorrow.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

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: 02/17/2021

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Continued from 809.

Observed lobby area all barricades from roof leak taken down. Designated point of entry through locked front door with COVID precautionary visitor signs posted. Observed designated and visitor and employee screen. Designee stated there is a designated screener is on all shift. LPA requested updated LIC500 to be submitted on 2/19/2021 to note who is the designated screener. PPE supplies available upon entry. PPE guidance sign not posted at PPE station, observed the sign posted in the location where the PPE station was before the roof leak. LPM recommended to move PPE station so it’s in an obvious place and review N95 reuse and CDC screening tools emailed on 2/7/2021 based on HAI recommendations on 2/6/2021 report.

Observed two staff restrooms in main lobby with soap, paper towels, hand washing sign posted, and touchless covered trash can. Disinfecting once every shift and Designee stated they do not have a designated restroom for staff caring for COVID positive residents, LPA provided recommended planning for how to designate restrooms for staff caring for negative residents and staff caring for positive residents. Disinfection and cleaning practices observed. Not all staff have their own cleaning solution and hand sanitizer. Observed two staff with alcohol and one with hand sanitizer. Currently using Ecolab peroxide with 3-5 minute SIT time. TM stated she completed in service training Zep with 60 second SIT time. Currently there are multiple products with variable SIT times being used, LPA recommended training for all staff on cleaning and disinfection of facility and creating a cleaning schedule to be submitted to the RO by 2/19/2021.

Observed room 104 paper towels sitting on the edge of the bathroom vanity and no toilet paper holder. Observed hourly logs for R3. Designee stated he was not moved out of his room, he refused, deep cleaning company used wiping rather than spraying. Hourly log documented R3 was not repositioned from 7am to 1pm today.

Observed room 118 observed paper towels sitting on the edge of the bathroom vanity and broken bathroom vanity that is not secured to the wall. Designee stated a lot of cabinets are in need of repair, a lot have broken cabinets and locks Designee stated maintenance employee has made a list of all repairs needed. LPA requested a copy of the list to be submitted to the RO by 2/19/2021.

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: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

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: 02/17/2021

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Continued from 809 C.

Observed room 223, COVID positive isolation room. Stocked PPE station outside of room with inventory sheet and COVID signs posted. Designee stated during deep cleaning COVID positive residents were moved into the hallway after the other residents were moved and then they went to their private smoking area outside.

Signed 809 reports to be submitted to the RO by 2/19/2021.

Five incident reports are being drafted and approved to be submitted to the RO by 2/19/2021.

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 2/19/2021.

· Residents reappraisal notes to be submitted to the RO by 2/19/2021.

Residents with updated Dementia diagnosis to be submitted to the RO by 2/19/2021.

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

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: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

LIC809 (FAS) - (06/04)

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