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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/01/2021
Date Signed: 03/01/2021 05:00:40 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 STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:PARKER, JADEFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 64DATE:
03/01/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jade ParkerTIME COMPLETED:
02:00 PM
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On 3/1/2021 Licensing Program Analyst (LPA) Ashley conducted an unannounced case management visit via Teams at 1pm with Administrator (ADM) Jade Parker. Today’s census is 54 on site.

The last line list submitted to the Regional Office (RO) was on 2/25/2021, updates have not been communicated to the RO since 2/25/2021. LPA requested ADM send it daily to the RO before the scheduled daily call. ADM stated he is adding the COVID test results on the Line List to be submitted to the RO by end of day 3/1/2021.

Resident one (R1) bumped his head on 7am on 2/26/2021, sustained slight bleeding, hospice came and addressed the injury. LPA requested hospice notes and SIR be sent to the RO on end of date 3/1/2021. Resident two (R2) incident on 2/26/2021 he was referred by CRISIS to be admitted to St.Joesph’s. LPA requested R2’s discharge plans from the hospital to be noted on the line list submitted to the RO by end of day 3/1/2021. Temporary Manager contacted conservator, they stated R2 would be staying at the hospital until alternate placement is found. Resident three (R3) is showing improvement on skin, commonly refusing repositioning every two hours, new hospital bed was delivered, no update on hoyer lift sling. Resident four (R4) is still not compliant refusing temperatures.

ADM stated roof repair work commenced on 2/23/2021. LPA requested an update including estimated time of completion is three weeks and a copy of the bid be be submitted to the RO by end of day 3/2/2021. Two water heaters were installed, hot water temperature now in regulation. LPA requested invoice for hot water heater installation and copy of hot water temperature logs be submitted to the RO by end of day 3/2/2021

Mitigation Plan not received. LPA requested Mitigation Plan be submitted to the RO by end of day 3/1/2021

Continued on 809 C.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
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 4
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: 03/01/2021
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Continued from 809.

At 1:35pm observed room 101, COVID yellow zone. Stop the spread, hand washing sign, hourly log, PPE donning signs posted outside the room. Stocked PPE station to the left of the door. Hourly log staff did not have sign off from 10am to 12pm and multiple staff signatures, no designated care staff assignment observed. RO requested submission of needs and services plan for Resident 5 (R5) to be submitted to the RO by end of day 3/1/2021. Observed no trash can inside outside of room and no COVID yellow sign on the exterior of the door, no night stand, no chair, no soap, and no stop sign or doffing instructions posted inside the room. Observed paper towels on sink counter and a broken toilet paper holder and toilet paper on the counter. R5 was observed napping in bed. ADM donned PPE to enter room including gown, N95, shield, and gloves, Doffed PPE inside the room and disposed of PPE in common hallway trash can that was not touchless with a foot pedal.

At 1:45pm during conversation with care staff about R5's needs and services plan, LPA observed staff one (S1)with N95 mask below her nose, her nostrils showing. Upon LPA’s request ADM instructed S1 to pull up her mask up.

At 1:50pm observed room 139 with no COVID precautionary measures implemented. ADM stated Resident 6 (R6) was going to be coming back to the facility from SNF today at 3pm.

Deficiencies were cited pursuant to California Code of Regulations Title 22 and Health and Safety Codes. Civil Penalties were assessed for repeat violations within the past 12 months. An exit interview was conducted with Parker. 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, LIC 809 D,Civil Penalties, and Appeal Rights were received. Parker 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 03/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidence by:
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Based on observation and interview the licensee did not protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that S1 did not to wear face coverings while providing care and supervision to clients in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions. This poses an immediate health and safety risk to residents in care.
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Type A
03/01/2021
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.
This requirement is not met as evidence by:
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Based on observation and interview the licensee did not protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that licensee did not follow recommendations from HAI for COVID-19 mitigation and precautionary measures in room 101 where COVID-19 person of interest is residing.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: 03/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2021
Section Cited

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87307 Personal Accommodations and Services(a) Living accommodations...(3) ...shall be readily available to each resident.. the licensee shall assure provision of: (B) a chair, night stand, a lamp, or lights sufficient for reading... This requirement is not bet as evidence by:
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Based on observation the licensee did not supply R5 in room 101 a chair and a night stand. This poses a potential risk to the health and safety of 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4