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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 04/28/2021
Date Signed: 04/28/2021 03:26:23 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:KARON MILLSFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 54DATE:
04/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Karon MillsTIME COMPLETED:
03:05 PM
NARRATIVE
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On 4/28/2021 Licensing Program Analyst (LPA) Ashley Boothe conducted an unannounced case management visit at 2:50pm with Administrator of record as of 4/8/2021, Karon Mills. Today’s census is 54. LPA explained the purpose of the call to review a reported incident of resident injury. A physical visit was not conducted in that the Department is not conducting visits at this time due to COVID-19 virus and precautionary measures.

On 4/16/2021 the Regional Office received an incident report for Resident one (R1) who suffered serious bodily injury on 4/13/2021. LPA reviewed records and conducted interviews and inspection. R1 was observed with serious bodily injury from a door, then assessed by the staff and home health nurse on site, and transported to hospital via emergency medical services. R1 returned to the facility with discharge instructions to follow up with primary care physician who referred R1 to a higher level of care on 4/14/2021. Staff one (S1) stated the doors where the injury occurred were heavy. Staff two (S2) stated the doors were heavy and closed fast. LPA observed doors to be heavy and closed quickly. S2 stated they were not aware of other instances of injury from the doors in the past two years.

Deficiencies were observed and given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Karon. 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, 809 D and appeal rights were received. Karon 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: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2021
Section Cited

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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, record review, and interview the licensee did not provide residents safe and healthful accommodations. R1 sustained serious bodily injury from a door known by staff to be heavy and close quickly which poses an immediate health, safety, and personal rights risk to the residents in care.
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The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(e) is currently under review (pending determination) and may be assessed on a later date, as a result of R1’s sustaining a serious bodily injury while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

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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: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2021
LIC809 (FAS) - (06/04)
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