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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/05/2021
Date Signed: 03/05/2021 03:29:30 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: DATE:
03/05/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jade ParkerTIME COMPLETED:
02:30 PM
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On 3/5/2021 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. Today’s census is 63, 53 on site. 5 residents are under isolation order as person of interest (PUI). As of today 50 residents tested positive of which 35 have cleared, 6 remain at a higher lever of care and 8 deaths. 14 residents and 48 staff tested on 3/2/2021 resulted in second round of negative mass testing. ADM stated he will contact LHD for further guidance. LPA provided updated LHD contact to ADM during exit interview.

Line List reviewed. Resident one (R1) now has 1:1 care outside room most of the day, still on isolation order as PUI. Resident two (R2) no changes in discharge plans. Resident three (R3) no changes, but facility will follow strictest guidance for PUI after brief hospital stay 3/3/2021. Resident four (R4) received personal care bath today, still non compliant.

Observed patio area, ADM stated ordered a sanitizer dispenser to put in the hallway in the stairs.



Paper towel dispenser delivered and will be installed after painting. Recommended to put up as soon as possible.

Observed yellow (PUI) rooms in AL. Observed PPE station fully stocked and all COVID signs posted in front of rooms 101-104. 103 and 104 signs posted on outside of rooms, but they are not set up to take residents. TM stated they will be ready Monday. Room 102 not observed on today’s visit. Observed ADM don PPE, practice hand hygiene, gown, gloves, was already wearing an N95 and face shield. Room 101 observed with all necessary furniture, COVID signs, Stop sign, PPE doffing signs posted inside and outside of room. Observed restroom soap, paper towels not mounted, and hand washing sign. Resident five (R5) observed in bed napping, ADM turned TV down. Cable cord observed on the ground, ADM coiled it up and will request maintenance to come cut the cable and secure it. Not able to observe ADM doff but he stated sequence of gown and gloves wrapped into a ball, hand hygiene, exit room, hand hygiene and spray shield with disinfectant. Observed hourly log for R5, LPA requested a copy of hourly log to review. Staff are checking on R5 every two hours and a gap at 4 am. Observed Staff one (S1) with sanitizer, disinfectant, N95 and surgical masks in pockets. LPA requested a copy of temperature screening log from 3/4/2021.

Continued on 809 C. Page 1 of 2.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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 2
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: 03/05/2021
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Continued from 809. Page 2 of 2.

Observed yellow (PUI) rooms in MC. Observed PPE station fully stocked and all COVID signs posted in front of room 127 and 129. At 2pm did not observe 1:1 staff posted outside R1’s room as previously stated and observed hourly log sign off at 12pm. At 2:20pm observed 1:1 staff posted outside room and hourly log signed off for R1’s care provided at 2pm, Staff two (S2) was inside room previously. Observed 134, resident watching tv, all drawers and cabinets opened and found to not store any toxins, restroom with soap, paper towels, hand washing sign posted, and covered touchless trash can. Observed MC kitchen with all drawers and cabinets opened and found to not store any toxins. Observed MC staff restroom with soap, paper towels, hand washing sign posted, and covered touchless trash can. Observed with 3 staff observed with sanitizer, disinfectant, N95 and surgical masks in pockets. Staff 3 (S3) stated common surfaces in between use for infection control. TM stated she is providing incentive for staff who carry all items. ADM also observed with supplies in his pockets.

No deficiencies were cited from Title 22. 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 was 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: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2