392700361-4-2-2021-27-AS-ABOE-BZPS6J-20210402133602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 04/02/2021
Date Signed: 04/02/2021 01:36:34 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:	04/02/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Robbie Cantoria		TIME COMPLETED:	11:30 AM

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On 4/2/2021 Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Liza King and Licensing Program Analyst (LPA) Ashley Boothe conducted an unannounced case management visit via Teams at 10am with Administrator Designee (ADM) Robbie Cantoria and Temporary Manager (TM) Maria Cantoria. Today’s census is 62, 51 on site. 4 residents are under isolation order as person of interest (PUI).

Observed entry, visitor policy, visitor logs. Staff and visitors enter the facility through ringing the locked front door, sanitizing supplies and PPE were available. COVID precautions signs posted and hand sanitizer was available throughout the facility.

Staff one (S1) stated the screening process and the team observed screening upon entry following screening process in Mitigation Plan. S1 stated essential visitors allowed entry to the facility. Other visitation is outside and visitors call to schedule, caregivers are notified to get the resident ready. If unannounced visitors arrive there is a second visitation area that can be used. S1 stated if visitors do not enter the building they do not screen visitors who come for outside visitation. Residents check in and out through designated screener. Visitors sign out o through designated screener Emergency medical personnel are allowed entry into the facility without full screening if medically necessary and S1 would screen them on the way out if time allowed and did not compromise resident care. S1 stated Office Manager discussed responsibilities and will provide them on a list to complete supportive office work. S1 stated there were 3 phones and the team observed cordless phone at screener desk. S1 stated resident was using the line and it was ringing on the other line when LPA called earlier and was unable to connect or leave a message. S1 stated disinfection of phone, dirty pens, thermometer, screening area every 15 minutes and after every visit the visitation area. Observed PPE stations stocked, inventoried on 4/2/2021 by S1 and posted Donning and Doffing sequences. S1 offers PPE to visitors if necessary.

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: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

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: 04/02/2021

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Continued from 809.

Observed communal dining room. Residents observed playing catch with a ball activity maintaining social
distancing, ADM redirected residents to properly wear masks. Temperature observed at 72 *F. Staff two (S2) stated Air Conditioner is currently not operational, the pump is not working. S2 stated resident complained of heat, S2 turned off heating system and turned on AC system but an error for broken pump was on. S2 was contacting AC service companies and using in house maintenance to attempt to resolve. S2 will provided an update to the RO. Observed thermostats around the building are the old style sliding system. Temperature observed 73 *F at 11:15am and 75* F at 1pm in dining room, doors open and fans available but one not turned on.

Observed kitchen, food supply of 2 day perishable and 7 day non perishable food unexpired and properly stored. Staff three (S3) left to purchase additional food supplies with the credit card.

Observed MC. Room 130 observed, resident refused entry and ADM directed staff to note when residents refuse activities. Observed room 139, residents observed sleeping. All necessary furniture was observed. R1 no agitation, noted as sleeping, no food intake because of choking. ADM requested staff to contact Hospice to reassess R1’s condition and order thickener. LPM recommended ADM request Hospice to come train staff on swallowing assistance. R2 has a radio and the old TV was broken and not repaired. LPA recommended providing R2 with a working TV for stimulation.

Observed AL. Room 108 isolation room prepared to take a PUI with all necessary furniture and COVID precautions as stated in Mitigation Plan. Room 114 isolation room with door open, PUI on isolation until 4/13/2021. R3 hourly log noted R3 had not eaten breakfast, Staff four (S4) stated R3 requested it to be left but had not attempted to eat it.

Deficiencies were observed and given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Robbie Cantoria. 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. Robbie 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: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

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: 04/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/09/2021 Section Cited	1 2 3 4 5 6 7	87303 Maintenance and Operation (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 is not met as evidence by:
	8 9 10 11 12 13 14	Based on observation and interivew the licensee did not maintain the Air Conditioner in working order as S2 stated the pump is broken which poses a potential health and safety risk 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: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

LIC809 (FAS) - (06/04)

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