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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/10/2021
Date Signed: 03/10/2021 02:36:13 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: 51DATE:
03/10/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jade ParkerTIME COMPLETED:
02:00 PM
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On 3/10/2021 Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an announced case management visit via Teams at 1pm with Temporary Manager (TM) Maria Cantoria and Administrator (ADM) Jade Parker. Today’s census is 62, 51 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 3/10/2021. 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 3/10/2021. Resident two (R2) coordination of personal items pick up this week. Resident three (R3) no changes. Resident four (R4) no changes in doctor’s orders for updates. Resident five (R5) SIR will be submitted documenting R5 removed from the community. Resident six (R6) is staying in room, keeping to their self, opening up to some care staff, LPA recommended review of care plan to incorporate more 1:1 actives to engage and socialize R6. Resident seven (R7) ADM will follow up with maintenance to fix tv and provide 1:1 actives to address R7’s interest while until isolation with the door closed.

ADM will submit 5 SIR’s to the RO by end of day 3/10/2021. LPM provided ADM recommendation for implementing a system for staff to document incidents and submit SIR’s to ADM for review and submission to the RO and provide updates to staff during daily stand up meetings.



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.

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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2021
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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