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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 04/14/2021
Date Signed: 04/14/2021 03:25:20 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: 54DATE:
04/14/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Karen MillsTIME COMPLETED:
03:30 PM
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On 4/14/2021 at 8am Licensing Program Analyst (LPA) Ashley Boothe conducted an unannounced health and safety check with facility Staff one (S1) and Executive Director Karen Mills (ED) Today’s census is 54 on site. LPA toured facility with S1, ED, and Staff three (S3).

Observed entry, visitor policy, visitor logs. LPA entered through ringing the locked front door and was screened by Staff two (S2) with updated CDC screening. LPA delivered PPE supplies to S2. LPA observed S2 sanitize the area in between visitor and staff use. PPE supplies were available near the sign in sheets. COVID precautions signs posted and hand sanitizer was available throughout the facility. PPE stations observed located outside isolation rooms and throughout the facility. Residents and staff observed wearing masks in communal areas. Observed staff redirect two residents to wear their masks, residents complied with direction.

Observed second seating of communal dining at breakfast with 4 residents socially distanced. Observed staff disinfecting tables after use. Observed communal activities with residents socially distanced as stated on activity calendar. Observed at 72*F.

Observed AL first floor. Observed Staff four (S4) complete medications pass for Resident 1 (R1) under isolation order as PUI. Observed S3 don and doff PPE in proper sequence to enter room. 4 of 4 medications observed properly labeled, properly stored and medications count matched MAR and Centrally Stored. At 8:32am observed room with isolation start and end dates not posted on door and S1 and S4 stated R1 is in a shared room with shared restroom with Resident two (R2) not on PUI, R1 was not moved into PUI isolation room per facility’s approved COVID Mitigation Plan. S1 immediately posted a sign on the door for R1’s isolation start and end dates.

Observed Resident three (R3) medications pass. 11 of 12 medications observed properly labeled, properly stored and medications count matched MAR and Centrally Stored. At 8:53am observed 1 of 12 medications not administered on 4/11/2021 at 6:00pm per physician's order, not noted on MAR resident refused. S4 was not able to find notes to document resident refusal or staff did not assist resident with medications administration. During interview R3 stated sometimes med techs forget to give me medications, not all of them, usually just one of them.

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

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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 4
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: 04/14/2021
NARRATIVE
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Continued from 809.

Observed PPE stations with posted Donning and Doffing sequences. At 8:40am observed less that 30 day supply of extra PPE stored in AL activity office. S1 stated additional PPE supplies have not been delivered.

Observed AL second floor. Resident four (R4) under isolation order as PUI door propped open with a trashcan. S1 instructed R4 to keep the door closed for rooms under isolation order for COVID precautionary guidelines. R4 stated it was too hot and S1 stated they would get R4 a fan for the room and AC unit was being maintenance today. R4 complied with keeping the door closed. At 9:13am observed temperature to be at 78*F in vacant room 202 with thermostat in on position set to 72*F fan was blowing but air was not cold.

Observed Memory Care unit. Observed Resident five (R5) under isolation order as PUI with hourly log check filled out with designated staff signature and Oxygen in Use sign posted on door. At 10:00am during interview ED stated Temporary Manager ordered a chair lift for MC stairwell access coming from second floor AL on 4/12/2021. 1 of 3 stairwells observed do not have chair lift. S1 stated they and Staff five (S5) are trained on using it.

Observed kitchen with unexpired foods properly labeled and stored in ample supply of 7 day non perishables and 2 day perishables. LPA observed temperatures in refrigeration and freezer units within acceptable range and temperature logs documented daily.

LPa reviewed three records.

Deficiencies were cited and given pursuant to Title 22 California Code of Regulations, Health and Safety Code. An exit interview was conducted with Karen. 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. Karen 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: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities(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 is not met as evidence by:
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Based on observation and interview the licensee did not ensure health and safety protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of residents in care, in that facility staff did not follow COVID mitigation straegies to keep residents on isolation chorted in rooms not shared with residents not on isolation, maintaing a supply of PPE, and ensuring isolation room doors are kept closed in violation of official government orders which poses an immediate health and safety risk to residents in care.
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Type A
04/15/2021
Section Cited

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1569.695(f)(1) Emergency Plans (f)(1) An evacuation chair at each stairwell on or before July 1,2019. This requirement is not met as evidence by:
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Based on observation and interview the licensee did not ensure an evacuation chair at each stairwell in the facility. 1 or 3 stairwells did not have a chair to use for resident evacuation. 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: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2021
Section Cited

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (5)The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidence by:
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Based on records reviewed and interviews the licensee did not ensure a plan to assist residents medication administration as needed. 1 of 12 medications observed not administered on 4/11/2021 per physican's order and not noted resident refused which 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: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4