392700361-3-11-2021-27-AS-ABOE-BZ22LK-20210311162942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/11/2021
Date Signed: 03/11/2021 04:30:17 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: 52	DATE:	03/11/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jade Parker, Administrator		TIME COMPLETED:	02:05 PM

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On 3/11/2021 Licensing Program Analysts (LPA’s) Ashley Boothe and Christina Valerio, Licensing Program Manager (LPM) Liza King conducted an announced case management visit via Teams at 1pm with Administrator (ADM) Jade Parker. Today’s census is 62, 52 on site. 7 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 level of care and 8 deaths.

Line List reviewed from last update on 3/11/2021. Resident one (R1) LPA requested Hospice notes and hourly log from 2/10/2021 to current to be submitted to the RO by end of day 3/11/2021. Resident two (R2) no changes. Resident three (R3) no changes. Resident four (R4) no changes. Resident five (R5) no changes. Resident six (R6) no changes. Resident seven (R7) ADM will follow up with maintenance to fix tv and provide 1:1 activities to address R7’s interest while until isolation with the door closed.

ADM will submit 4 SIR’s to the RO by end of day 3/12/2021.

LPA requested a copy of the visitor and staff screening log to be submitted to the RO by end of day 3/12/2021.

Quality Assure Nurse is reviewing all resident’s medications and will submit audit findings to the RO by end of day 3/12/2021.

LPA requested updated LIC 500 to be submitted to the RO by end of day 3/12/2021.

LPA requested March Activity Calendar to be submitted to the RO by end of day 3/12/2021.

Continued on 809 C. Page 1 of 3.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

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 3

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: 03/11/2021

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Continued from 809.

Observed entry, visitor policy, visitor logs. Staff and visitors enter the facility through ringing the locked front door, sanitizing supplies and PPE were available near the sign in sheets. PPE inventoried by the maintenance team and conducting daily from 3/9/2021 to 3/11/2021. ADM stated they hired an additional maintenance staff. Activity calendar posted in communal area for residents and visitors. COVID precautions signs posted throughout the facility. Staff screening log includes temperature check and updated CDC symptom screening questions. Hand sanitizer was available throughout the facility.

Observed kitchen with ample food supply of 7-day non perishables and 2 day perishables in the refrigerator. No expired or improperly stored foods observed. Observed temperature logs filled out. ADM stated light bulb in freezer has not been repaired. Expired dietary certificate was removed. ADM stated there is a broken pipe in the kitchen. Water was coming out of a wall faucet and Roto Rooter came out to camera the line and found a blockage, corroded pipe and water damage. Currently there is no damage to the inside the kitchen, no water is backing up inside the kitchen and repairs are taking place on the other side of the wall. Plumbers have requested staff temporarily not use the third sink for dishwashing and ADM stated they have access to the food prep sink and hand washing sink and meals are served one disposable serve ware. Observed communal dining room. The facility is not engaging in communal dining at this time.

Observed residents rooms 224 and 229 in AL. All necessary furniture was observed. Restroom in 224 had soap, unmounted paper towels, touchless foot pedal trash can, and hand washing signs posted, ADM stated they were going to paint before mounting the paper towels. Observed uneaten lunch and hourly log noted he refused lunch today, Resident eight (R8) stated he was taking time. Restroom in 229 had soap, unmounted paper towels, no touchless foot pedal trash can, and no hand washing signs posted but the resident moved out a couple months ago.

Continued on 809 C. Page 2 of 3.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 03/11/2021

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Continued from 809 C.

Observed residents room 108 in AL in process for isolation protocols to be implemented.

Observed residents room 111 in AL. All necessary furniture was observed. Restrooms had soap, paper towels, touchless foot pedal trash can, and hand washing signs posted.

Observed residents room 127 in MC. All necessary furniture was observed. Restrooms had wall mounted soap, wall mounted paper towels, touchless foot pedal trash can, and hand washing signs posted. Observed room 129 Isolation room with door closed and ADM stated R7 is still eating. LPM recommends that MC staff have access to peri care products on them or locked and secured in residents rooms rather than to go get it from locked storage at the end of the hallway.

Observed MC outside patio shade structure removed. Observed staff restroom with no soap ADM stated staff was getting the refill, with paper towels, touchless foot pedal trash can, and hand washing signs.

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.

Page 3 of 3.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

LIC809 (FAS) - (06/04)

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