392700361-3-24-2021-27-AS-ABOE-BZEUD7-20210324152900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/24/2021
Date Signed: 03/24/2021 03:29:39 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:	DATE:	03/24/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jade Parker		TIME COMPLETED:	02:00 PM

NARRATIVE

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On 3/24/2021 Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Liza King and Licensing Program Analyst (LPA) Ashley Boothe conducted an announced case management visit via Teams at 1pm with Licensee James Wong, Administrator (ADM) Jade Parker, and Temporary Manager (TM) Maria Cantoria. 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, 4 remain at a higher level of care and 8 deaths. 6 Hospice residents.

The team discussed the following:

Staffing: Regional Office (RO) requested written plan on current staffing plan and updated LIC500 be submitted to the RO by end of day 3/24/2021. Currently 50 applications on file, Craigslist ad posted yesterday and ADM stated tentatively scheduling interviews for Friday. When staffing agency contract is concluded there will be no on call assistance. Staffing contingency plan is multiple staff willing to work overtime. ADM stated they are hiring to replace on call staff.

Activates: RO requested activity calendar for the month of April by end of day 3/24/2021.

Maintenance and Repairs: Budget is as requested from Licensee on a daily basis.

Call Light system: No update at this time.

Food: ADM and Licensee budgeted weekly budget approved for food, activities, and supplies. Food will be purchased on Tuesday and Fridays.

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: 03/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021

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: 03/24/2021

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Continued from 809.

Line List reviewed from last update on 3/24/2021. Resident one (R1) ADM stated medication review completed and requested additional pain medications from Medical Director. (R2) no changes. Resident three (R3) ADM stated his baseline is complaining there is no skin break downs causing discomfort but is yelling every two hours during changing. Resident four (R4) no changes. Resident five (R5) no changes. Resident six (R6) no changes, Resident seven (R7) no changes. Resident eight (R8) admitted to hospital not at baseline, RP was notified. Discharged from hospital yesterday with suppository Tylenol, TM stated MD referred for Hospice. R8 was not administered Tylenol suppository prior to readmission to hospital.

SIR submitted to the RO from ADM on 3/23/2021 for incident on 3/20/2021 of bed bugs in rooms 123, 121, and 119. Resident nine (R9) stated inching ,redness, and markings. Evidence of bed bugs observed in rooms, resident’s relocated, and Pest Control serviced on 3/20/2021. ADM stated isolated incidences from previous infestation and not a new occurrence.

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 3/24/2021. Updated LIC 500’s will be submitted as staffing changes.

ADM will submit 3 SIR’s and resubmit 1 SIR to the RO by end of day 3/25/2021.

RO requested 5 resident care plans submitted to the RO for review by end of day 3/24/2021

RO requested Hospice notes for R3.

Vaccination records to be submitted to the RO for review by end of day 3/24/2021.

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 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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3

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: 03/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/31/2021 Section Cited	1 2 3 4 5 6 7	87303 Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:
	8 9 10 11 12 13 14	Based on observation and documentation. On 3/24/2021 incident reports stated that there is bed bugs at the facility which poses a potential health and safety risks to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: 03/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021

LIC809 (FAS) - (06/04)

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