392700361-6-14-2021-27-AS-VBRN-C3Z4NL-20210614191520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/14/2021
Date Signed: 06/14/2021 07:15:55 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 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: 54	DATE:	06/14/2021
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	06:15 PM
MET WITH:	Barbara Williams		TIME COMPLETED:	07:30 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 facility Applicant Sandeep Saini and Barbara Williams 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: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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
	VISIT DATE: 06/14/2021

NARRATIVE

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Licensing Program Analyst Victoria Brown arrived unannounced at the facility on 6/14/21 at 6:15pm to conduct a health and safety check. LPA met with Barbara Williams, Wellness Director who assisted with todays visit.

LPA and Barbara toured the facility inside and outside to ensure the safety of the residents in care and that there are no hazards. LPA interviewed a random amount of residents during this visit. The residents had a variety of food for dinner such as hamburgers, french fries, fruits, chips and dessert and beverages and evening snacks has been prepared for later. Upon arrival the residents were receiving medication pass. LPA observed two Medication Technicians/Caregivers and 1 Caregiver on the Memory Care side along with 2 Caregivers on the Assisted Living side. LPA observed the kitchen area and ample food supplies. LPA observed the elevator to be working with a notice of recent request for inspection and portable air conditioners.

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: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

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