392700361-6-8-2021-27-AS-VBRN-C3T5P6-20210608200726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/08/2021
Date Signed: 06/08/2021 08:07:50 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:	KARON MILLS		FACILITY TYPE:	740
ADDRESS:	517 E FULTON ST		TELEPHONE:	(209) 466-2116
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	114	CENSUS: 52	DATE:	06/08/2021
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	07:00 PM
MET WITH:	Barbara Williams		TIME COMPLETED:	08:15 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	During today’s visit Licensing Program Analyst's (LPA's) Victoria Brown contacted the Henry Emojebbe with the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? (NO) · Fever or chills · Cough · Shortness of breath/difficulty breathing · Fatigue · Muscle or body aches · Headaches · New loss of taste or smell · Sore throat · Congestion or runny nose · Nausea or vomiting · Diarrhea Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? No Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? No Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? No Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? No Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? No Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? No

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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 2

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: 06/08/2021

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
26
27
28
29
30
31
32

Licensing Program Analyst(s) Victoria Brown and Sarah Hurt arrived unannounced at the facility on 6/8/21 at 7pm to conduct a health and safety check. LPAs met with Barbara Williams, Wellness Director who assisted with todays visit.

LPAs and Barbara toured the facility inside and outside to ensure the safety of the residents in care and that there are no hazards. LPAs interviewed a random amount of residents during this visit. The residents had a variety of food for dinner such as Beef tips and noodles and carrots and beverages and sandwiches if requested. Upon arrival the residents were receiving medication pass. LPAs observed two Medication Technicians on the assisted living side and 1 Medication Technician on the Memory Care side along with 1 Caregiver on the Memory Care side. LPAs observed the kitchen area was locked and Barbara does not have a key. The Administrator was contacted who confirmed the kitchen key is locked in her office and the Designated person who is Barbara does not have the key. LPAs observed water and snacks and pizza available for residents as a evening snack also. LPAs observed the elevator to be working and portable air conditioners on both floors. LPAs also observed silver ware in the kitchen area that will be used to set the tables for the residents use at meal times.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2