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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/12/2021
Date Signed: 06/12/2021 10:41:51 AM

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: DATE:
06/12/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Henry EmojevbeTIME COMPLETED:
10:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Health and Safety inspection on 6/12/2021 at 8:15am. LPA met with Designated Staff Henry Emojevbe and stated the purpose of today’s visit. LPA was allowed entry into the facility with current census of 53 residents of which 4 are on 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 in various locations between 75*F and 80*F within the required range of 68*F and 85 *F. LPA observed air conditioning units in working order pumping cool air into the facility and fans. LPA observed ample food supplies of staple nonperishable foods and fresh perishable foods recently purchased within regulatory range of 7 day non perishable and 2 day perishable food supplies to be maintained on site at all times. Hot water measured at 119.2*F within required range of 105*F to 120*F. LPA observed patios in Memory Care and Assisted Living with debris and spills on the ground, provided technical assistance to clean the areas. LPA observed 4 of 4 medications counted matching PRN records. LPA observed residents engaged in activities of exercise and crafts. LPA observed room 243 unoccupied with a bubble in the ceiling from water damage currently under repair. Today's staffing includes 5 caregivers, 3 med techs, 4 dietary staff, 1 housekeeper, and 0 administrative staff/driver on site during the visit.
LPA reviewed documents provided to designate administrator of record not submitted to the department not signed by licensee. As of 6/10/2021 there is no administrator of record on file with the Department.

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 and 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: 06/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2021
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: 06/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2021
Section Cited

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(a) All facilities shall have a qualified and currently certified administrator....

This requirement is not met as evidence by:
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Based on observation and interview the facility Administrator of record last day was 6/10/2021. Plan of Correction to submit documnets to associate new administrator not signed by licensee. As of today's date there is no administrator of record on file with the department which poses a 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: 06/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2021
LIC809 (FAS) - (06/04)
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