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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 03/26/2021
Date Signed: 03/26/2021 12:17:31 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: 52DATE:
03/26/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jade ParkerTIME COMPLETED:
11:00 AM
NARRATIVE
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On 3/26/2021 Licensing Program Manager (LPM) Liza King and Licensing Program Analysts (LPA’s) Ashley Boothe and Michael Bilger conducted an unannounced case management visit via Teams at 9am with Administrator (ADM) Jade Parker. Today’s census is 62, 52 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 residentson

Vaccination records are being verified though pharmacy consent forms as of today everyone who has signed consent form has received first and second dose of vaccination.

ADM stated they do not have a tablet for resident use and he will purchase one today. Current practice is to use personal staff cell phones for resident communications.

The Regional Office(RO) requested the following records for review. As of today’s visit items not received.
  • Updated POC for citations issued on 3/23/2021
  • Planned LIC 500 for when all staffing support is removed
  • Updated LIC 500 will be submitted as staff schedules change
  • 4 SIR’s and resubmit 1 SIR
  • 5 care plans
  • Hospice notes for R3
  • Vaccination records
  • Line list submitted daily


Continued on 809. Page 1 of 3.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
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 5
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: 03/26/2021
NARRATIVE
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Continued from 809. Page 2 of 3.

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 TM 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.



Observed PPE stations stocked, inventoried on 3/26/2021 and posted Donning and Doffing sequences. Extra PPE is stored in office N95 and the rest of PPE is stored separate storaADM stated process for staff were given supply of 7 N95 they were fit tested on and reuse for 5 days and ask ADM for extra supply. Last PPE training was via video on Monday for caregivers and last Donning and Doffing was on 3/14/2021. Observed Staff 1 (S1) donning and doffing. S1 stated disinfection after exiting each isolation and quarantine, sometimes sprays N95 with alcohol for reuse. Observed Staff two (S2) donning and doffing. Two methods observed by S1 and S2.

Observed kitchen, ADM stated food on hand was adequate and purchasing Tuesday and Friday. Staff three (S3) stated their plan was shopping on Saturday. S3 observed not wearing N95 properly. Observed soap, paper towels, touchless foot pedal trash can, and hand washing signs were available at kitchen hand washing sink.

Observed communal dining room. The facility is not engaging in communal dining at this time. The plan for communal dining to resume will be included in the mitigation plan addendum to be submitted to the RO by end of day 3/29/2021.

Observed second floor staff break area with chairs not socially distanced, signs posted to encourage social distancing, disinfection after use, staff observed not wearing a mask while not eating.

Observed second floor staff restroom was stocked with soap, paper towels, touchless foot pedal trash can, and hand washing sign.

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

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 03/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2021
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
This requirement is not met as evidence by:
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Based on interview and records review the Licensee did not submit requested documents as agreed upon timelines to the Department which poses a potential health and safety risk to residents in care.
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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) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 03/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2021
Section Cited

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87405 Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to: (3) Develop an administrative plan and procedures to ensure clear definition of lines of responsibility, equitable workloads, and adequate supervision.
This requirement is not met as evidence by:
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Based on observation and interview the licensee did not maintain a plan to ensure resident's needs are met through clear definition of responsibility, delegation, and supervision which poses an immediate risk to health and safety risk to residents in care.
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Type A
03/27/2021
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.
This requirement is not met as evidenced by: .
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Based on observation and interview the licensee did not ensure staff follow procedures as directed. This poses an immediate health and safety risk to residents in care.
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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) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 03/26/2021
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Continued from 809 C. Page 3 of 3.

Observed chemicals stored in AL janitorial closet. Staff four (S4) stated Zep and is used to disinfect in between use or in between use and SIT time is 1 minute and peroxide with 3-5 minutes- sometimes it depends on how dirty and use it for 4 minutes. S4 stated caregivers help clean too. Two housekeeping staff on the schedule today. S4 stated practice is to clean common areas first then residents’ rooms. Residents rooms are cleaned once a week and some rooms cleaned daily. S4 stated changes gloves in between cleaning activities. House keeping staff have the key to the housekeeping closet and extra key in the maintenance closet and all staff have access to it. ADM stated his keys are kept in office not on his personal key ring. All staff have access to keys in MC and ADM stated they are making copies of keys.


Observed residents’ room 131 in AL not ready per isolation protocols. Observed trashcan, signage, PPE instructions, restroom, handwashing sign, paper towels, trash can, chair, night stand, and lighting. Stop sign and doffing signs not posted. ADM stated staff will posted signs and laundry hamper will be moved from resident’s room upon entry.

Observed residents room 132 in MC. All necessary furniture was observed. Restrooms had soap, paper towels, touchless foot pedal trash can, and hand washing signs posted. No personal care products observed in communal areas.

Observed medication’s room in MC. Requested Centrally Stored, MARs and PRN log for R1 and R7 to be submitted for review to the RO by end of day 3/26/2021. Observed R1 and R7’s medications. ADM stated the last MC medications audit was on Tuesday, ADM stated it was not documented, there was an audit form but has not documented and medication audits. ADM stated last medications audit in AL was Monday. ADM stated they are in the middle of switching from bubble pack to zip packs effective 4/1/2021.

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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5