392700361-3-22-2021-27-AS-ABOE-BZCU95-20210322152233

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/22/2021
Date Signed: 03/22/2021 03:23:37 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: 51	DATE:	03/22/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jade Parker		TIME COMPLETED:	02:10 PM

NARRATIVE

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On 3/22/2021 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, 51 on site. 5 residents are under isolation order as person of interest (PUI). As of today 50 residents tested positive of which 35 have cleared, 4 remain at a higher level of care and 8 deaths.

Staffing plan discussed. ADM stated he plans hire 8 staff. 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 will submit 2 SIR’s and resubmit 1 SIR to the RO by end of day 3/22/2021.

Line List reviewed from last update on 3/22/2021. Resident one (R1) ADM stated he will purchase a bed alarm today as R1 is ambulating. LPM recommended ADM implement fall prevention practices. ADM stated SIR will be resubmitted with further documentation. (R2) no changes. Resident three (R3) no changes. Resident four (R4) no changes. Resident five (R5) no changes. Resident six (R6) has started to come socialize at night, coming out when there is less activity, RO requested R6’s care plan submitted to the RO for review by end of day 3/22/2021 Resident seven (R7) no changes. LPA requested room assignments be updated on the Line List to be submitted to the RO for review by end of day 3/23/2021

Bed bugs found in rooms 123, 121, 119, pest control treated.

Vaccination records to be submitted to the RO for review by end of day 3/23/2021.

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: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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: 03/22/2021

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Continued from 809.

Activity calendar posted and observed 3 residents in AL engaging in puzzles and balloon toss. ADM stated Aya staff are doing actives. Observed MC activity egg painting at a table in the hallway. LPM recommended moving to the MC communal dining room to provide more residents engagement while maintaining social distancing. ADM stated the Aya staff have been buying supplies and TM is reimbursing him.

Observed kitchen food supply. ADM stated dinner change to menu because they were out. The US Foods order was not received on 3/19/2021 and the last food delivery/pick up was on 3/17/2021. Kitchen staff was currently at Costco purchasing food supply. Observed kitchen with food supply less than 7-day non perishables and less than 2-day perishables in the refrigerator including low stock of vegetables.

126 observed with all necessary furniture was observed. Restrooms had soap, paper towels, touchless foot pedal trash can, and hand washing signs posted. Observed oxygen tank not in use. ADM stated it was supposed to be picked up last week and requested staff remove it from the room. RO requested R8 and R9’s care plan submitted to the RO for review by end of day 3/23/2021

Deficiencies were observed and given pursuant to Title 22 rules and regulations, Health and Safety Codes. 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, LIC 809 D 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: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/23/2021 Section Cited	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on observation and interview the licensee did not maintain a 7-day non perishables and 2-day perishables in the facility which poses an immediate risk to health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 03/23/2021 Section Cited	1 2 3 4 5 6 7	87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B)"No smoking oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on observation and interview the licensee did not post an "Oxygen in Use" sign on room 126 where oxygen was observed inside the room which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

LIC809 (FAS) - (06/04)

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