392700361-3-12-2021-27-AS-CVAO-BZ32CC-20210312161631

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/12/2021
Date Signed: 03/12/2021 04:17:27 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: 53	DATE:	03/12/2021
TYPE OF VISIT:	Case Management - COVID-19	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jade Parker, Administrator		TIME COMPLETED:	01:32 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/12/2021 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 63, 53 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) sitting up in bed, eating lunch, and in a really good mood today. Resident two (R2) ADM reported the conservator office is picking up belongings today and no update on next placement. Resident three (R3) ADM reported no more instances of yelling or grabbing of staff, hospice three times weekly. Resident four (R4) no changes, ADM will follow up with doctor regarding med non-compliance. Resident five (R5) ADM stated he reached out to referral agency. Referral agency is still looking for alternative placement. Resident six (R6) ADM reported designated care staff conducted individual activities, such as, stretching and exercises. Resident seven (R7) ADM will follow up with maintenance to fix tv, ADM will confirm 1:1 activity on hourly logs. ADM stated there are no new incidents to report. Roto Rooter is working on a bid for the kitchen/salon. ADM stated as soon as licensee approves the bid, Roto Rooter can get someone one out to the facility. ADM reported they are working on replacing the fences and the roof. Bids for the fence are coming in. ADM may decide to buy materials and use own maintenance staff to complete work. ADM reported the facility hired a few Medication Technicians, interviewed a few Care Givers, and have separated two new Medication Technicians from the company this week Continued on 809 C Page 1 of 2

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

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
	VISIT DATE: 03/12/2021

NARRATIVE

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Continued from 809

Quality Assurance Nurse reviewed all resident’s medications on 03/11/2021.Temporary Manager (TM) is in the process of conducting a full audit today and will submit memory care audit findings to the RO by end of day 03/12/2021 and assisted living audit findings to the RO by end of day 03/15/2021.

ADM will coordinate with TM to determine if facility will continue with mass testing or move to surveillance testing.

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

ADM will submit updated LIC 500 to the RO by end of day 3/12/2021.

ADM will submit March Activity Calendar to the RO by end of day 3/12/2021.

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.

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SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

LIC809 (FAS) - (06/04)

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