392700361-5-7-2021-27-AS-LKIG-C2SV99-20210507161357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 02/24/2021
Date Signed: 05/07/2021 04:14:04 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:	DATE:	02/24/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	05:09 PM
MET WITH:	Maria Canteria		TIME COMPLETED:	06:30 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	LPM started the virtual tour in the kitchen area, floor was dry and it appeared that the sewage issue has been resolved. Temperature at the sink in the kitchen measured 121 degrees, there was a hot water above 120 degree sign posted. Walk-in fridge, no food present on the floor, food properly labeled. Dry storage area observed, LPM looked under dry storage, three rat/mice traps present and empty. No droppings from bvermin observed behind doors, behind ice maker and under sink. Observed the large dining room chairs were socially distanced, 2 staff were present, wipes were present. Council Meeting was conducted today at the community, resident present in the a seating area working on a puzzle. Two of three staff questioned had cleaning solutions on their persons. PPE station in hall present, with hand sanitizer last inventory 02/24/21. No masks present, all removed from PPE stations all staff are provided 7 masks every Monday and the staff sign off of masks that they have been fit tested on. LPM observed the N95 stock approx 33 boxes plus masks for residents. Screening of roof repair men were verified and present. Employee bathroom near outside of memory care water temperature checked at 122 degrees. Trashcan observed, soap and towels present. MCN RM 129 no mattress protector, trash can with lid, liner in hamper, water temperature at 121 degrees. Alert push button in BR not working and no pull cord system in room RM 122 Alert push button in BR not working and no pull cord system in room PPE station complete outside of positive room. Resident checked every hour and screened every 4hours RM133 alert button in BR pushed not working. Water temp taken 122 degrees. Additional staff asked for cleaning solution did not have it on her person.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

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: 02/24/2021

NARRATIVE

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Room 125 chirping fire alarm, staff to fix (fore dept was out earlier this week has been chirping since). Resident lieing in bed, wearing a long sleeved dark grey sweatshirt and navy blue pants. Residents reported that she went to church service today, TM reported that she went to resident council meeting. When asked how she asks for help, resident stated that she yells for help if she needs help, she then pointed to the call cord but stated she never used it. LPM observed the pull cord, with a 3 inch "shoe lace" tied to it, TM pulled cord, system not working, LPM observed a full laundry basket of dirty clothes near nightstand. TM asked resident if she was showered today, resident reported no, and stated she needs help tpo shower. Resident was talkative and pleasant. Resident reported that the last time it rained, water was leaking from "there" and she pointed to the fire sprinkler system on the ceiling then pointed above her head area on the ceiling, however there was no evidence of a leak. Resident was not asked anything about a leak, she divulged this information on her own. Next to the residents bed within reach was a wheelchair. LPM observed the room, which had a tv and radio, a cane was in the closet and another next to the residents bed within reach, she offered it to fix the fire alarm chirping. No walker appeared to be present.
Rm 108 water from sink yellow as it pours out originally 107 degrees, TM reported water was adjusted current time 604pm.
Back to original employee bathroom water temperature 124. TM requested hot water sign be posted. Follow up will be conducted.

Deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview was conducted with TM Maria Canteria Copy of the report sent to Jade Parker, via e-mail with a "read receipt" to verify the LIC 809 and appeal rights were received. Jade Parker is to print out the report, sign it, and email a signed copy to LPA

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

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: 02/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/25/2021 Section Cited	1 2 3 4 5 6 7	87303(e)(2) - 87303-Maintenance and Operation-Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105' F and not more than 120' F.. Based on the temperature reading, the facility is in violation of this section. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on observation the licessee did not ensure that the water temperature is within an acceptable range. The LPM observed the temperature to be between 107-124 degress. This poses an immediate risk to residents in care.	8 9 10 11 12 13 14
Type B 03/05/2021 Section Cited	1 2 3 4 5 6 7	Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:(A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (c)Identify the specific resident living unit. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	The licensse did not ensure that the signal system was in working order, based on observation the LPM observed 5 of 5 rooms that did not have a call system that was working, in addition to staff interview.	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: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

LIC809 (FAS) - (06/04)

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