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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/18/2021
Date Signed: 06/18/2021 04:08:08 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:ANURADHA SAINIFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 54DATE:
06/18/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Anuradha Saini and Eddie ItliongTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct a Health and Safety Inspection on 06/18/2021 at 9:25 AM. LPA Martinez met with Anuradha Saini and stated the purpose of today’s visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate # 6056677740 and expires on 06/30/2021. The facility is licensed for 114 non-ambulatory residents. There are currently 54 residents who reside at this facility. The facility has a hospice waiver for 10, and there are currently 4 residents receiving hospice services. Additionally, there are 19 residents residing in memory care wing.

LPA Martinez toured the facility with Josefina Rodriguez, Dinning Director, on 06/18/2021 at 9:25 AM. The facility dinning room area temperature is 70 degrees. The facility main entrance lobby has 2 portable AC units. First portable AC unit temperature is 76, and the second portable AC unit temperature is 73 First floor assisted living wing has 1 portable AC unit, which the temperature is 80 degrees. First floor memory care wing temperature is 80 degrees. The second floor assisted living wing has 4 portable AC Units. The 2 left-back portable AC temperatures are 81, 85 degrees. The 2 right-back portable AC temperatures are 83 and 82 degrees.

Each resident apartment has it's own installed AC unit. Furthermore, residents are able to control the temperature settings. LPA Martinez observed a broken thermostat in room 124. LPA Martinez observed one portable AC unit in the memory care unit. A second portable AC unit was installed in the memory care unit during the visit. In addition, the memory care common dinning room is under construction. Also, the facility provides water and ice cream to residents during heat waves. The facility also has water and Ice cream reminder posters in the lobby.

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SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
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 3
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: 06/18/2021
NARRATIVE
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LPA Martinez observed unknown unassociated employee residing in room 222. LPA Martinez observed unknown unassociated employee belongings in room 222. LPA Martinez was informed by the administrator that the employee was not associated, and this employee would vacate the room immediately.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations, The deficiencies were cited on 809-D. Additionally, civil penalties are being issued during today's visit. Failure to correct the deficiency may result in further civil penalties.


Exit interview conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: 06/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2021
Section Cited

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87355(e)(1)Criminal Record Clearance...All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department...
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This requirement was not met as evidence by: based on observation and the administrator stating unknown/unassociated employee was not associated to the facility, nor has obtained a criminal record clearance. This 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3