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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 05/30/2021
Date Signed: 05/30/2021 03:31:07 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:
05/30/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Barbara WilliamsTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Health and Safety inspection on 5/30/2021 at 1:50pm. LPA met with designated facility staff Barbara Williams and stated the purpose of today’s visit. LPA was allowed entry into the facility with current census of 53 residents of which 5 are hospice.

LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. The temperature inside the facility was measured at 78 *F in common dinning room, 79 *F in Assisted Living (AL) first floor, 82 *F in AL second floor, and 80 *F in Memory Care (MC) within the required range of 68*F and 85 *F. LPA observed 6 air conditioning units in working order pumping cool air into the facility and fans. The outside temperature at the time of the visit was 86 *F, Barbara stated she contacted to rent two additional air conditioning units in preparation for higher temperatures forecasted. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed MC medications count 12 of 12 medications to match centrally stored and Mar's, and no missed resident's medication administration observed. LPA observed residents in MC kitchen with door to housekeeping closet unlocked leaving toxins accessible to residents in care. LPA observed gate to MC patio with closing latch not in working order allowing MC residents access to unsecured patio. LPA observed food supplies of staple nonperishable foods and fresh perishable foods on site as staff were returning and unloading food supplies during today's visit. Today's staffing included 3 caregivers, 3 med techs, 4 dietary staff, and 1 administrative staff/ driver on site during the visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.49 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2021
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: 05/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2021
Section Cited

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Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirment is not met as evidence by:
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Based on observation and interview the licensee did not ensure cleaning supplies and disinfectants were stored inaccessible to residents in that the housekeeping closet in the Memory Care unit kitchen was unlocked which poses an immediate health and safety risk to residents in care.
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Type A
05/31/2021
Section Cited

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Care of Persons with Dementia (h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.
This requirment is not met as evidence by:
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Based on observation and interview the licensee did not ensure the outdoor space for resident recreation was completly enclosed and secured. The gate was unlocked without a self closing latch in working order which poses an 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: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2021
LIC809 (FAS) - (06/04)
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