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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/23/2021
Date Signed: 06/23/2021 05:41:24 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: DATE:
06/23/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Barbara WilliamsTIME COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Health and Safety inspection on 6/23/2021 at 3:00pm. Prior to today's visit LPA called the facility for COVID screening and was unable to get through, phone line disconnected. LPA screened COVID upon entry. LPA met with Designated Staff Barbara Willams and Administrator Anuradha Saini 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 and accompanied by Barbara throughout the inspection.

LPA interacted with a random number of residents during this visit. The physical plant was toured inside to ensure the safety of the residents. The temperature inside the facility was measured at 75*F within the required range of 68*F and 85 *F and in areas of extreme heat the maximum shall be 30*F less than the outside temperature. LPA observed phone lines not in working order, not allowing any incoming calls but outgoing calls can be made. Administrator stated they had not yet notified residents, resident responsible parties, ALWP, and Ombudsman of emergency contact number to use until repairs are made as previously discussed, but were working on compiling a list of contacts.

LPA observed ample food supplies of staple nonperishable foods and fresh perishable foods within regulatory range of 7 day non perishable and 2 day perishable food supplies to be maintained on site at all times. LPA observed residents engaged in activities and dining.

Room 222 not in use by residents with personal belongings to be cleared out of personal belongings not cleared out as of today's date, Barbara stated it is not in use and will remove the remainder of personal items not in use. Room 216 accessible on today's visit on today's date with staff personal belongings.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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 4
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: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2021
Section Cited

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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance...(5) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidence by:
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Based on record review and interview the licensee did not ensure medications were administered as physician's order. R1 was not administered medications at 6am on 6/22/2021 and 2pm on 6/23/2021 which poses an immediate health and safety risk to the residents in care.
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Type B
06/28/2021
Section Cited

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Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidence by:
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Based on record review and interview R1's room was not found to be clean and sanitaary in that the room was found to have bed bugs and not treated timely which poses a potential health and safety risks 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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 06/23/2021
NARRATIVE
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 Continued from 809.

LPA observed June Medication Administration Records (MAR)'s. Two residents with missed medication administration as physician's order on 6/22/2021 and one resident on 6/23/2021. R1 stated medication was missed at 2pm today and 6am yesterday.

R1 stated they had moved rooms about 5 weeks ago because of bed bugs and wanted to return to their room but it had not been treated for the bed bugs yet. LPA observed resident room without a bed and R1's personal belongings still in the room. No record of pest control services for bed bug treatment available in the facility. No incident report submitted to the Department on file for R1's bed bugs. Barbara and Staff one (S1) stated they had not seen anyone come to treat the room. S1 stated they looked in R1's room for further evidence, did not see any, cleaned R1's belongings, and threw away the bed, but was unsure if the bed bugs were still present.

Today's staffing includes 2 caregivers, 3 med tech/caregiver, 2 dietary staff, 2 housekeeping, and 4 administrative staff on site during the visit. LPA observed construction in Memory Care Dining room and MC door and exterior gate propped open allowing residents access if left unsupervised. LPA provided technical assistance to keep the are secure or assign a staff to ensuring all residents can not access the patio with construction materials including nails, paint, and tools.

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: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2021
Section Cited

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Reporting Requirements (a) Each licensee shall furnish to the licensing agency...
(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident
This requirement is not met as evidence by:
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Based on observation and record review the licensee did not submit an incident report for R1's bed bugs identifed in R1's room which poses a potential health and safety risks to residents in care.
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Type B
06/30/2021
Section Cited

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Telephones All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.
This requirement is not met as evidence by:
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Based on observation and interivew the phone system is not in working order so that no incoming calls come through which poses a potential health and safety risks 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: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4