392700361-3-19-2021-27-AS-ABOE-BZ9USY-20210319155107

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/19/2021
Date Signed: 03/19/2021 03:52:07 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:	03/19/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jade Parker		TIME COMPLETED:	03:00 PM

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On 3/19/2021 Regional Manager RM Krystall Moore, Licensing Program Manager (LPM) Liza King, and Licensing Program Analysts (LPA) Ashley Boothe conducted an announced case management visit via Teams at 1pm with Administrator (ADM) Jade Parker and Temporary Manager (TM) Maria Cantoria. Today’s census is 62, 52 on site. 5 residents are under isolation order as person of interest (PUI). As of today 50 residents tested positive of which 36 have cleared, 4 remain at a higher level of care and 8 deaths.

The team discussed plan for staffing when TM contract ends. TM has provided ADM training and technical assistance to contain COVID outbreak and the expectation moving forward to maintain what TM has implemented. RM requested updated LIC 500 with staff not working removed and a planned LIC 500 for when all staffing support is removed to be submitted to the RO for review by end of day 3/22/2021. Updated LIC 500’s will be submitted as staff schedules' change. ADM stated he has learned a lot from TM he plans to hire new staff and keep some older staff. Currently there are 11 staff that are contracted though TM and staffing agency support. ADM has a plan to hire 5 additional staff, move staff out of dietary, and cross train all staff to be a caregivers and participate in resident activities. TM stated they have started transitioning all regular staff to am but are still struggling with pm, swing, and noc shifts as that is were the majority of call outs are are. ADM stated he plans to hire on call staff as well. Currently there is no Infection Preventionist on staff and ADM is planning to put Quality Assurance Nurse into the role.

ADM will submitt 2 SIR’s to the RO by end of day 3/19/2021.

Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

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: 03/19/2021

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Line List reviewed from last update on 3/17/2021, LPA requested updates on the line list to be submitted to the RO by end of day 3/19/2021. Resident one (R1) fall on 3/17/2021, medication order changes started on 3/18/2021. LPM recommended a fall risk prevention plan (R2) all belongings were picked up Friday, no additional information provided to ADM. Resident three (R3) no changes. Resident four (R4) conservator’s office is in contact with MD for conservatorship. Resident five (R5) no changes. Resident six (R6) has started to come out to socialize. Resident seven (R7) unwitnessed fall on 3/13/2021 lead to room change and door kept open. ADM stated staff is no longer 1:1 but still doing hourly checks.

Vaccination records reviewed; 58 residents listed. 30 vaccinated with first dose of which 8 are awaiting second dose. 4 residents refused vaccination. 21 noted as not vaccinated and 3 off site at a higher level of care. ADM stated not that many staff wanted it, but it is continued to be offered. N95 fit testing is completed for all current staff and ADM stated new staff will use designated medical facility for fit testing and health screening upon hire.

ADM stated food on hand is enough and ADM is purchasing two to three times a week. The team observed kitchen with ample food supply of 7-day non perishables and 2 day perishables in the refrigerator and pantry. ADM stated communal dining is closed but planning to do multiple seating’s of with cohorted roommates at tables together. Currently the dining room can accommodate about 24 residents at a time. MC will use patio as weather permits.

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. Staff one (S1) stated the screening process and the team observed her screening a staff upon entry following screening process in Mitigation Plan. COVID precautions signs posted and hand sanitizer was available throughout the facility. Residents and staff observed wearing masks in communal areas, one resident ADM redirected to pull mask up.

Observed residents’ room 101 and 103 in AL not ready per isolation protocols. Observed trash can, signage, PPE instructions, lined laundry hamper, hand washing sign, paper towels, trash can, chair night stand, and lighting. 101 did not have a mattress or a dresser and 103 did not have an adequate mattress. ADM stated he would purchase and have maintenance set up rooms. LPM recommended moving the bed so that residents can be observed by staff from opening the door.

Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

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: 03/19/2021

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Observed residents room 104 and 125 in AL. All necessary furniture was observed. Restrooms had soap, paper towels, touchless foot pedal trash can, and hand washing signs posted. Observed R6 was watching TV and stated she was depressed. ADM stated no socializing noted on the log. ADM stated he would come back for an activity when he was off the call.

Observed residents room 139 in MC. All necessary furniture was observed. Restrooms had soap, paper towels, touchless foot pedal trash can, and hand washing signs posted. LPM recommended moving chairs further apart to maintain social distancing.

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 and appeal rights were 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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

LIC809 (FAS) - (06/04)

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