392700361-4-20-2021-27-AS-MBIR-C29W46-20210420165702

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 04/20/2021
Date Signed: 04/20/2021 04:58:16 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:	KARON MILLS		FACILITY TYPE:	740
ADDRESS:	517 E FULTON ST		TELEPHONE:	(209) 466-2116
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	114	CENSUS: 54	DATE:	04/20/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Karon Mills, Administrator, Maria Cantoria, Temporary Manager		TIME COMPLETED:	02:50 PM

NARRATIVE

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On 04/20/2021 at 1:00pm, Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Stephanie Doub and Licensing Program Analysts (LPA’s) Ashley Boothe and Michael Bilger conducted an unannounced case management visit via Teams at 1:00pm with Administrator (ADM) Karon Mills and Temporary Manager (TM) Maria Cantoria. LPAs met with ADM and TM and explained the purposes of today’s visit. Today’s census is 54 on site, 4 residents are on isolation. 2 of the 4 residents on isolation are scheduled to come off on 4/23/21. There are no active COVID cases currently.

Adm hired 2 med techs and 1 driver on 4/19/21. An LIC 500 is to be submitted by end of today 4/20/21 by Adm. Adm. also to submit updated mitigation plan by 4/21/21.

Adm stated it was comfortable and LPA’s observed temp at 71 degrees.

TM stated a new transportation company is under contract – “Covenant Transportation” Company will provide transport for residents to and from medical appointments and other personal needs.

LPA 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. 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 with 30-day supply. Extra PPE is stored in activities room. Observed staff donning and doffing procedures. PPE was last inventoried on 4/19/21. LPA suggested ADM. develop a back up plan to ensure PPE is inventoried daily.

A chair lift is placed at the stairwell. Administrator to follow up on a back-up chair left which is scheduled to arrive on 4/23/21.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

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: 04/20/2021

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Observed kitchen with food supply of 7-day non-perishables and 2-day perishables in the refrigerator and pantry. Freezers are stocked with frozen meats ADM stated food on hand is enough. Adm stated food was purchased today and will also be purchased tomorrow. Observed soap, paper towels, touchless foot pedal trash can, and hand washing signs were available at kitchen hand washing sink. Kitchen sharps were secured and locked. Dishes were clean and properly stored. Thermostat in kitchen read 75 degrees.

Observed communal dining room. 10 staff members are scheduled to surveillance testing to be performed today 4/20/21 in the dining room. Temperature in dining room read 71 degrees on thermostat.

Observed chemicals stored in housekeeping closet which was locked and secured. LPA observed a housekeeping cleaning schedule for resident rooms which noted all rooms receive daily general cleaning by caregivers and daily deep cleaning done by housekeepers.

Observed residents’ room #101 and #104 in AL. Observed trashcan, signage, PPE instructions, lined laundry hamper, restroom area, handwashing sign, paper towels, trash can, chair nightstand, and proper lighting.

Adm has instructed med tech to audit MAR at every shift change. An audit sheet is in place and shall be cross reported with on-coming shifts. All resident records to be audited at this time per Adm. and to be submitted to Adm for resident. LPA requested a copy of audit form to be submitted by end of day 4/20/21.

Observed residents’ room #127 and #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 grooming items observed on dresser tops.

LPA observed daily logbook containing food and liquid intake as well activities.

LPA observed call button response by caregiver under 30 seconds.

Observed MC patio door which requires repair. Adm. to follow up on repair status.
LPA observed emergency binder in place and accessible to appropriate staff. LPA suggested to Adm to acquire

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

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: 04/20/2021

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	a permanent generator. An exit interview was conducted with Karon Mills, Adm. 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. Karon Mills to print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at Michael.Bilger@dss.ca.gov.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC809 (FAS) - (06/04)

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