392700361-2-16-2021-27-AS-ABOE-BYB6AL-20210216193830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 02/16/2021
Date Signed: 02/16/2021 07:39:07 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:	02/16/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jade Parker and Maria Cantoria		TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an announced case management visit via Teams at 1pm with Temporary Manager (TM) Maria Cantoria and Administrator (ADM) Jade Parker. Mass testing on 2/11/2021 resulted negative, TM stated all tested negative and 3 were undetermined. 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.

Line List reviewed. Residents are in the process of being reappraised by newly appointed Medical Director (MD). 17 LIC602’s have been completed this week and the remainder of reappraisals will occur tomorrow. Resident one R!, COVID positive is put on Hospice 2/12/2021 is in decline. Resident two (R2) is receiving 1:1 care to redirect aggressive behaviors towards furniture, staff, and residents. Resident three (R3) is showing skin integrity problem, refusing to repositioning every two hours, MD will assess for Hospice tomorrow.

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).

· Results from 2/11 testing to be submitted to RO on 2/17/2021.

· 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.

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: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

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: 02/16/2021

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Continued from 809

TM stated tomorrow staff and residents will undergo weekly mass testing. West Coast and Fire Company are scheduled 9:30am-12:30pm for deep cleaning, disinfection, and decontamination. MD will be visiting the facility to provide medical reappraisals to update resident’s LIC 602’s. LPM will send an updated invite for the daily call to be rescheduled to 3pm.

TM stated she anticipates 7 residents to be put on Hospice. LPA confirmed the facility has an approved Hospice Waiver for 10. TM stated a lot of residents are showing sundowning. TM requested Memory Care capacity and LPA will review and provide TM and updated on the 2/17/2021 daily call. TM stated she purchased a bicycle and vibrating machine to support resident’s care plans.

TM stated activity coordinator has been hired and LPA will clear POC for deficiency cited on 2/10/2021 once LIC500 is submitted. PPE requested from the RO including medium and large gloves, gowns, N95 masks L188. TM stated PPE was ordered from MOHAC last Wednesday and ADM will reorder today. TM stated assigned lead staff to monitor to hourly log checks to ensure resident care is documented. TM stated temporary fix recommendations from professional roofer were taken and in house maintenance work completed. Barricades in lobby have been removed.

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: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC809 (FAS) - (06/04)

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