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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/08/2021
Date Signed: 03/08/2021 04:14:22 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: 53DATE:
03/08/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jade Parker and Maria CantoriaTIME COMPLETED:
02:00 PM
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On 3/8/2021 Licensing Program Analyst (LPA) Ashley Boothe 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 62, 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, 5 remain at a higher lever of care and 8 deaths.

Line List reviewed from last update on 3/5/2021. Resident one (R1) positive changes in condition walking in the hallway with 1:1 care provided in full PPE and increased nutrition. LPA requested Hospice notes and hourly log for 3/6 and 3/7. Resident two (R2) TM stated Ombudsman advocated for them to look for alternative placement, no discharge plans. Resident three (R3) is yelling at night. Resident four (R4) no changes, still non compliant.

ADM will submit 5 SIR’s by close of businesses 3/8/2021 to LPA.



Blackout incident over the weekend resulted in loss of power to a part of the facility for approximately 1.5 hours and the entirety of the facility for approximately 1.5 hours. LPA requested LIC 610E by end of day 3/8/2021.

Dementia Care Plan of Operations to be submitted to the RO by end of day 3/9/2021


TM stated 3 residents (2 MC 1 AL) are slated to move into the facility once physician's reports and preadmission appraisals are updated and complete.

ADM submitted the request for renewal for elevator inspections dated 3/8/2021.

TM will submit updated staffing plan differentiating staffing from TM contract, staffing contract, and regular staff. LPA will provided PIN 21-14ACS for updated guidance on personnel COVID vaccination and tuberculosis testing recommendations.

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: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
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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