392700361-3-9-2021-27-AS-LKIG-BYY4LX-20210309181241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/09/2021
Date Signed: 03/09/2021 06:13:28 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:	03/09/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	ADM Jade Parker		TIME COMPLETED:	03:15 PM

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On 3/9/2021 Licensing Program Analyst (LPA) Ashley Boothe, LPA Christina Valerio and Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Teams at 1pm with Administrator (ADM) Jade Parker. Today’s census is 52 on site. 8 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 level of care and 8 deaths. Although the facility has had 2 rounds of negative tests, they have chosen to mass test again today.

Line List reviewed. One resident sent to ER yesterday due to general weakness and remains at Dameron, no updates today. Two residents that are currently PUI’s are non complaint with isolation and facility rules and left yesterday without signing out to go to the store. Adm is currently seeking alternative room arrangements for the two in hopes that they will stay isolated together and not leave the facility or their room to go to the others room. Tour of the entry of the facility to include all necessary signage, screening area, front bathroom, mounted sanitizer, and PPE stations, inventory last taken on 03/01/2021. LPM recommends the ADM find a process for PPE stations to be inventoried, ensuring that staff have the necessary tools to safely perform their duties.

5 staff members observed throughout the building of which 2 were wearing their N95 masks incorrectly, LPM pointed it out and asked for it to be corrected. 2 of 5 staff did not have the necessary cleaning supplies on their persons. LPM recommends a refresher training of all staff on an ongoing basis of PPE Donning and Doffing. In addition, as previously recommended the Adm needs to provide correction and direction to staff.

8 residents in isolation, which is different than previously reported verbally by Adm (per yesterday’s report). LPM observed the four room area that has been identified as the yellow area. Only two of the rooms are currently in use. The other PUI’s are placed at the end of the hallway.

Cont. on 809C

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021

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: 03/09/2021

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The LPM recommends that the facility review its mitigation plan as it relates to a yellow zone, and a red zone in preparation for residents that may exhibit symptoms, return from a higher level of care or new admissionsLPM toured two PUI’s in MC. One of two doors open and accessible, LPM questioned the reason for the door being open, Adm reported that resident gets agitated with the door closed and stated the same for the other resident, LPM discussed a plastic barrier that would allow staff to monitor through and resident to see light from hallway through as an idea to alleviate not having the door shut. Another suggestion would be to have the designated staff member present in PPE in the residents room providing different forms of socializations and stimulation. LPM observed the proper signage on the exterior of the doors, the hourly logs and PPE station. LPM observed a staff member donn and enter the room. Present in the room was the resident lying in bed, showered today and clean shaven. Soap, paper towels and a trash can were observed in the residents restroom. The cabinet beneath the sink was locked. LPM asked if the staff needed periwash to provide care where would it be kept. Staff member explained that prior to providing care, the staff member would have to find someone with a key to unlock the cabinet. LPM recommends having a key accessible to designated staff whom are providing care in the isolation areas.

Staff reported that the other resident in MC is agitated and scratches and bites during brief changes. LPM observed the MAR and recommends the facility evaluate the resident’s current condition and collaborate care with hospice and staff LVN to meet the residents needs. LPM also recommends updating the needs and services plan. The facility staff may benefit from pain management education.

An exit interview was conducted with Parker and Maria Canterio, Temporary Manager (TM). 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: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021

LIC809 (FAS) - (06/04)

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