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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 04/30/2021
Date Signed: 05/03/2021 12:15:59 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:
04/30/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karon Mills, AdministratorTIME COMPLETED:
01:06 PM
NARRATIVE
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At 9:00am Licensing Program Analysts (LPA’s) Michael Bilger and Ashley Boothe, conducted an unannounced Case management visit. LPA's met with ADM and stated the purpose of the visit.

The facility current capacity is 114 non ambulatory residents with Hospice Waiver for 10. Current census is 54 on site. 7 of 7 staff observed with criminal record clearance associated in the Licensing Information System (LIS).

LPA's toured the facility with ADM. Staff and visitors enter through designated point of entry, a locked front door with COVID signs posted. Designated care staff screened LPA's for COVID screening and took temperatures prior to entry. At 10:00am LPAs observed COVID screener not in lobby with front door entry accessible. ADM stated designated screener called off sick today. Observed stocked PPE station and visitor logs filled out. Main entry with water damage on the ceiling and broken lighting fixtures from roof leak. Resident's Personal Rights, Resident Counsel, and Let Us Know posting in main area accessible to all residents, family, visitors, and staff. LPAs proved technical assistance to ADM to provide larger 20x26 complaint poster. Observed common staff restroom unlocked, with soap, paper towels, hand washing sign, and touchless covered trash can. Observed elevator maintenance last serviced 03/08/2021 with COVID precautionary 1 person in elevator at a time posted. Observed COVID precautionary signs posted, PPE stations, and sanitizer throughout the facility.

At 11:00am LPAs observed kitchen. Prepared food temperatures were taken in April and recorded. Ample food supplies of 7-day perishable, and 2 days non-perishables, and emergency food stored. Menu matched what



{This is an amended version of the report originally created on 4-30-21}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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: 04/30/2021
NARRATIVE
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was served for lunch today. Kitchen staff posted California Food Handlers cards posted, 2 were unexpired, and S1 stated there were valid cards on her phone that need to be printed. Floors clean and kitchen was in overall good repair. Washing system was last serviced in January of 2021. Semiannual maintenance on fixed Ansul system last serviced on 03/2021. Hand washing sink with soap, paper towels, hand washing sign, and covered. Hot water signs posted to notify of water above regulatory range. First aid kit was new and unopened. Refrigerator temperature was 40 degrees F and within adequate range per regulations.

Observed dining room with tables and chair setup for social distancing and communal meals and small group activities.

At 10:32am LPAs observed Assisted Living (AL) Medications Room. Hot water in medications room faucet was not in working order. No hot water was running when turned on. Resident's medications were stored separately and properly labeled. 2 of 2 medication counts matched MARs.

Observed 3 resident rooms in AL. Rooms observed with all necessary furniture and lighting. Restrooms observed with non-slip shower floors and grab bars. LPAs observed yellow zone room with all necessary signage posted with trash can covered but not touchless.

LPAs toured room #104 and #201. Hot water temperature is room #104 measure 112.1 degrees F. Room #201 measured 109.8 degrees F.

3 stairwells were observed to have chair lifts. Air Conditioning units upstairs and downstairs observed to not be functioning properly. A maintenance company was on site and currently working on the unit. Facility temperature read 83 degrees F upstairs at 10:06am and 77 degrees F downstairs dining room at 10:51am.

At 9:26am observed Memory Care (MC) Unit with locked delayed egress doors working. LPAs observed doors of resident rooms propped open with a shoe and door stop. Doors in multiple resident rooms were observed to not close properly.

Observed kitchen and dining area in MC with doors secured. Chemicals were stored securely in closet.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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
VISIT DATE: 04/30/2021
NARRATIVE
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Observed outside patio of MC unit. Unit was clean and in good condition.

At 9:42am observed MC unit medications room with medications labeled. Observed 1 of 1 medications. Medications matched MARs upon observation.



Based on today’s visit, deficiencies were cited under Health and Safety Codes Chapter 3.2 and per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Karon Mills and a copy of this report and appeal rights was provided to Karon Mills by LPAs via email with a "read receipt" to verify the 809 and appeal rights were received. Karon is to print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA Michael Bilger at michael.bilger@dss.ca.gov.

{This is an amended version of the original document created on 4-30-21}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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: 04/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/03/2021
Section Cited

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87303(e)(3) Taps delivering water at 125 degree F (52 degree C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
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Based on observation, licensee did not ensure a warning sign above the faucet in the laundry room for water temperature measuring above 120 degrees F. This poses an immediate health and safety risks to residents in care.
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Type A
05/03/2021
Section Cited

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87303(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. The requirement is not met as evidenced by:
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Based on observations and intervierws, Licensee did not ensure propeAC unit operation; did not ensure doors to muliple resident rooms shutting properly; did not ensure bulbs and ballasts were operating properly; did not ensure water damage in entry way was repaired; did not ensure MC door was shutting properly; did not ensure working hot water in AL med room
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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: Michael BilgerTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4