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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/19/2021
Date Signed: 06/19/2021 12:07:28 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:
06/19/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH: Henry EmojevbeTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Health and Safety inspection on 6/19/2021 at 10:15am. Prior to today's visit LPA called the facility for COVID screening and was unable to leave a voicemail message at between 8am and 9am, voicemail box full. LPA screened COVID upon entry. LPA met with Designated Staff Henry Emojevbe 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 Henry 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 in various locations between 72*F and 81*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 10 portable air conditioning units, fans, and central air conditioning system in working order. LPA observed phone lines in working order ringing but voicemail system not accepting messages. Administrator stated staff has cleared voicemail boxes but fill to quickly to maintain. LPA provided technical assistance to notify residents, resident responsible parties, ALWP, and Ombudsman of emergency contact number to use until new phone system replaces current system, anticipated completion next Tuesday . 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 unoccupied residents rooms in AL first and second floor. Room 222 not in use by residents with personal belongings to be cleared out of personal belongings as maintenance crew stated they break outside now and room 222 no longer in use. Room 216 inaccessible on today's visit as staff off site had the key, stated it was used for their belongings and will return on Monday. LPA observed residents engaged in activities, exercise, and eating lunch. Today's staffing includes 6 caregivers, 2 med tech/caregiver, 2 dietary staff, 2 housekeeping, and 2 administrative staff on site during the visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2021
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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