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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 04:15:57 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:
03/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jade ParkerTIME COMPLETED:
04:15 PM
NARRATIVE
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On 3/8/2021 Licensing Program Analyst (LPA) Ashley Boothe conducted an unannounced case management visit phone call at 4:00pm with Administrator (ADM) Jade Parker to follow upon a Special Incident Report (SIR) sent to the Regional Office (RO) via fax documenting an incident of missed medications for Resident one (R1) and Resident two (R2). Today’s census is 62, 53 on site.

The SIR stated on 2/14/2021 at approximately 8am, R1 and R2 informed Medtechs Staff one (S1) and Staff two (S2) they did not receive their 8pm medications on 2/13/2021. Upon review of Medication Administration Records, TM and ADM confirmed that Staff three (S3) was in charge of the medications pass at the time and R1 and R2 did not receive medications as prescribed by physician’s orders.

On 2/14/2021, at 12:35pm Temporary Manager (TM) notified Medtechs via text of an emergency meeting at 1:30pm regarding the missed medication instances and additional medications management training. At approximately 12:40pm S3 left the building without informing ADM or TM. ADM received email notification shortly after of S3’s resignation.

Deficiencies were observed and given pursuant to Title 22 rules and regulations, Health and Safety Codes. 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, 809 D, 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: 03/08/2021
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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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: 03/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2021
Section Cited

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (5)The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidence by:
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Based on records reviewed the licensee did not administer R1 and R2's medications on 2/13/2021at 8pm documented on R1 and R2's MAR's as physicans' ordered which poses an immediate health and safety risk to 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: 03/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2021
LIC809 (FAS) - (06/04)
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