<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 04/01/2021
Date Signed: 04/01/2021 04:40:02 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: DATE:
04/01/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria CantoriaTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/01/2021 Licensing Program Manager (LPM) Liza King and Licensing Program Analysts (LPA’s) Ashley Boothe and Michael Bilger conducted an announced case management visit via Teams at 1:00 pm with Temporary Manager (TM) Maria Cantoria and current licensee James Wong

LPA discussed with TM the Incident report for: Resident one (R1):



According to TM Logs of when resident was last checked on by staff, Physician’s report (LIC 602), and Needs and service plan will be submitted by end of day 4/1/21. PCP was contacted and is working with PCP for follow up on memory care issues at this time for R1. PCP Originally came 3/30/2021 to address this issue. In addition, according to TM, PCP will order Home Health. Resident is currently participating in activities and attended a town hall meeting. No current changes at this time since last incident.

TM stated a new med cart is in place with new keys ordered. A toolbox has also been ordered from Amazon as a backup.

Incident report regarding missing Hydrocodone has not yet been submitted. Police were also notified of incident according to TM. Incident report is due to RO by end of day on 4/1/2021

Phone system continues to have malfunctioning issues with callers unable to get through. Only phone lines not working is TM and front desk. According to TM, a staff meeting was held to stress the importance of notifying all RPs to address the phone issues.

A new staff member (S1) will be involved in a job sharing role as a COVID screener at the front door and assisting with housekeeping supplies, filing system, mail sorting, and other miscellaneous duties. In addition, 2 new staff members have been hired since last meeting. TM will update LIC 500 and submit to
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
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 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
VISIT DATE: 04/01/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CCLD to reflect the schedules of S1 and new staff.

Currently there are 3 staff members that are not fit tested at this time.

TM stated a resident has passed away and will send death report for R2

TM stated that AC was not working properly, and a new resident was complaining of temperature. According to administrator, temperature inside the facility got as high as 88 degrees F. TM to update CCLD on the proper functioning of the AC

TM stated that 3 staff members will fill in for Administration duties each will do a 12-hour shift on a rotating basis. TM will submit a new LIC 308 and LIC 500 to reflect these changes.

Potential new licensee stated that they are attempting to find a new Administrator at this time.

According to TM, dietary manager is ensuring that food supply is adequate with a weekly budget able to cover other supplies such as cleaning and activity supplies.

Weekly calls will continue Mondays, Tuesdays, and Thursdays.

After TM’s departure from facility on 4/5/21, the Email account will remain active for communication

Deficiencies were cited per Title 22 regulations based on today's visit.

An exit interview was conducted with Maria Cantori. 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. Maria Cantori is to 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: Michael BilgerTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 2 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: 04/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2021
Section Cited

1
2
3
4
5
6
7
87468.1 (a) (2): (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met:
8
9
10
11
12
13
14
Based on record review and staff interviews, licensee did not ensure healthful accommodations. Memory care med tech locked keys med cart resulting in 5pm medications missed and 8pm medication given 9pm which poses immediate health safety risk to residents .
8
9
10
11
12
13
14
Licensee will submit a plan to designate a custodian of keys to ensure someone will always be able to access med carts. Plan to be submitted to CCLD by POC due date of 4/5/21.
Type B
04/12/2021
Section Cited

1
2
3
4
5
6
7
Residents... shall have all of the following personal rights: To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. The requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on staff interview and observation, licensee did not secure adequate
operation of facility’s phone system resulting in calls unable to be retrieved by residents in a timely manner. This poses a potential 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3