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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 10/28/2020
Date Signed: 10/28/2020 03:39:30 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:PARKER, JADEFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 80DATE:
10/28/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Jade Parker administrator TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Diego Escobar contacted the facility to conclude a case management visit via telephone due to COVID-19 and pre-cautionary measures. A telephone call made to this facility on 10/28/2020 and this LPA was able to speak with the facility Administrator Jade Parker who was briefly interviewed and explained the purpose of the call. Current census was 80 residents.

On October 5, 2020, the Sacramento South Regional Office received an incident report Jade Parker, Administrator stating Resident 1 (R1) was not given medication appropriately. LPA Escobar interviewed Administrator and requested documents in regards to this incident. R1 moved into the facility on September 25, 2020. Upon review by LPA, R1's Medication Assistance Record indicated that R1 was not assisted with several following medications: Medication 1 (M1) was not given to R1 from September 26 through September 27, 2020, medication 2 (M2) was not given to R1 from September 26 through September 27, 2020 and medication 3 (M3), medication 4 (M4), medication 5 (M5), medication 6 (M6) and medication 7 (M7) were not given to R1 from September 26 through September 28, 2020.

According to Mayo Clinic, the proper use of M3 is listed as "Do not change the dose or stop using this medicine without checking first with your doctor. When your supply of this medicine is running low, contact your doctor or pharmacist ahead of time. Do not allow yourself to run out of this medicine."

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in additional civil penalties. Appeal rights were provided. Exit interview conducted with Jade Parker. Copy of the report sent to Jade via e-mail with a "read receipt" to verify the LIC 809, LIC 809-D, LIC 811 and appeal rights were received. Jade is to print out the LIC 809 and LIC 809-D, and fax signed copies to LPA at 916-263-4744.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2020
Section Cited

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(f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as...assistance with taking prescribed medications...
This requirement has not been met as evidenced by:
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Based on record review, and interview the licensee did not comply with the regulation cited above by not assisting R1 with his prescribed medications, 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) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2020
LIC809 (FAS) - (06/04)
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