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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 05/14/2021
Date Signed: 05/14/2021 02:06:55 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: 53DATE:
05/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Karon MillsTIME COMPLETED:
12:30 PM
NARRATIVE
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LPA Michael Bilger arrived at facility on 5-14-21 at 9:15am to conduct a case management visit due to recent incident report received on 4-20-21 regarding a fall episode. LPA met with Karon Mills, Administrator (ADM) and informed her of the purpose of the visit. According to incident report dated 4-17-21, R1 sustained a fall and a bruise to the forehead. A record review of R1 was conducted. An interview with Administrator and Staff 1 (S1) was also conducted. LPA requested and received the following documentation from ADM: 9-1-1 protocol, incidental medical and dental plan of care, April staff scheduling for AL unit, Nurse coverage schedule for April, care notes for 4-17-21 and 4-18-21, and Nursing communication notes to Physician on 4-17-21 and 4-18-21. Based on interviews and record reviews, 9-1-1 was not notified after resident fell and sustained a bruise to the forehead. Per Medical Emergency policy of the facility furnished by Administrator 9-1-1 is to be called when “resident exhibits signs and symptoms of distress and/or emergency condition.….examples include: (d) Fall with deformity, severe pain, or head injury.” Administrator stated that 9-1-1 should be called when a resident falls and hits his/her head.

During today’s case management visit LPA also reviewed care notes for R1 which included a note that read on 5-1-21 at 1:13pm “no meds given today” due to unpaid pharmacy balance by responsible person. Upon further record review of R1’s MAR it was determined that resident did not receive medications from the period of 5-1-21 to 5-4-21.

Based on today’s visit, deficiencies were cited under Title 22 regulations, Division 8. A copy of this report and appeal rights were left with Karon.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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: 05/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2021
Section Cited

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87465 Incidental Medical and Dental Care. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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This requirement is not met as evidenced by:

Based on interviews and record reviews, licensee did not ensure 9-1-1 was called and timely response to medical attention given to R1 after sustaining a fall with injury. This poses an immediate health and safety risk to residents in care.
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Type A
05/17/2021
Section Cited

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87465 Incidental Medical and Dental Care (5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Based on record review and interview, licensee did not ensure medication was given to R1 between the period of 5-1-21 and 5-4-21. This poses and 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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2021
LIC809 (FAS) - (06/04)
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