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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 10/01/2020
Date Signed: 10/01/2020 08:19:56 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: 78DATE:
10/01/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Andrew CorpuzTIME COMPLETED:
04:45 PM
NARRATIVE
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LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check of R1 and other residents in care. LPA met with Andrew Corpuz and was later joined by Joel Toledo. The Administrator was out at a doctor's appointment.

LPA observed staff on duty and the residents eating lunch in the dining hall. LPA toured the facility with Joel Toledo, during the tour LPA observed unlocked medications in room 110 and 121, LPA smelled malodorous odors from multiply rooms including the memory care wing, LPA observed in an empty room seven bags of dirty resident clothing without labels, the A/C in the Memory Care area is not working, this was by confirmed staff that it has been out for weeks. LPA observed a resident in room 108 on the assisted living side that was sent to the ER on 9/24/2020 and returned from the ER on 9/29/2020 was not isolated and has a cough. She is on oxygen and the room is not identified with this information.

LPA was informed by residents that other residents are drinking and smoking marijuana in common areas. The facility is aware of the situation and plans on having a meeting with those residents about the use of drugs and alcohol at the facility. LPA was informed that a staff person was sent home on 9/28/2020 for signs and symptoms of illnesses related to Covid -19 and was informed on 10/1/2020 that person tested positive for Covid.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020
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 4
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: 10/01/2020
NARRATIVE
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Health and Safety checks performed and all residents are at risk for exposure to Covid -19 the facility has no plan in place to mitigate the risk of exposure to staff or residents. LPA directed facility staff to printed out CDC and CDSS best practices for Covid-19 related issues.

LPA obtained copies of resident and facility information. During the records review LPA observed R1 with an outdated service plan and S1 has no history of orientation training.

Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview conducted. Copy of LIC 809, LIC 809-D, and appeal rights provided. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 10/01/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2020
Section Cited

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The following requirements shall apply to medications which are centrally stored:(1) Medications shall be centrally stored under the following circumstances:
B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed.
(C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.
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This requirement was not met as evidenced by: During tour of facility, LPA observed unlocked medications in a residents room with the door open. This poses an immediate health and safety risk to residents in care.
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If the residents do not self administer their medication the facility will conduct an inservice to address the unlocked medication. Copy of plan is due to CCL by 10/02/2020.
Type A
10/16/2020
Section Cited

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Basic Services (f)Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)..."Care and supervision" means the facility assumes responsibility for,... ongoing assistance with activities of daily living ...
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This requirement was not met as evidenced by observation, records reviewed and interviews conducted that the facility failed to provide basic services for residents in care. This posed an immediate health and safety risk
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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) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 10/01/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2020
Section Cited

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87405 Administrator-Qualifications and Duties:(d) The administrator shall have the qualifications specified in Sections 87405...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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This requirement is not met as evidenced by: Based on interviews and file reviews The Administrator failed to follow facilities' care and supervision policies. This posed an immediate health and safety risk to residents in care.
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Training topics and dates shall be submitted by POC date, 10/02/2020

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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) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4