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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/28/2021
Date Signed: 06/28/2021 01:30:30 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:ANURADHA SAINIFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 54DATE:
06/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anuradha Saini, AdministratorTIME COMPLETED:
01:20 PM
NARRATIVE
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On 6/28/21 at 9:30am, Licensing Program Analyst (LPAs) Michael Bilger and Bruce Jacobs conducted an unannounced pre-licensing visit. LPAs met with Administrator Anuradha Saini and explained the purpose of the visit. LPAs were accompanied by Administrator and toured the facility inside and out, including the kitchen. Temperature in building was 76*F throughout. Kitchen contained adequate food supply. LPAs checked itemized list of repairs. Roof in lobby has been replaced, RV and non-working bus have been removed from the property, battery has been replaced in the ansul system; Administrator stated fire inspection is scheduled for today 6-28-21 to verify working ansul system. A request for permit was noted in the elevator. Administrator will follow up with elevator service company to obtain permit. Paper towel holders were noted in resident rooms. Light bulbs and ballasts were in working order. Memory care cabinets have been repaired. Window screens have been repaired. Memory care patio fence has been replaced. Memory care patio wires, pipes, and drip lines have been repaired. Memory care delayed egress door was not functional upon testing. Memory care activity door has been repaired. Telephone system has been upgraded and call forwarding is now in place. Resident rights posting are in place. Door stoppers have been removed from resident doors.

At this time, the following repairs are necessary to proceed with license approval: Memory care door and alarm with appropriate signage, verification of fire inspection for ansul system, permit for elevator to be obtained.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2021
Section Cited

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(a) When approved by the person responsible for enforcement...exit doors in facilities..housing residents with alzheimer's disease may be equipped with egress-control devices...The devices shall conform the requirement: (1) Automatic deactivation of the egress-control device upon activation of...the detection system.
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This requrement is not met as evidenced by:

Based on observation, licensee did not ensure memory care delayed egress door did not alarm upon testing by LPA. This poses and imeediate health, safety, and resdient rights risks to residents in care. Immediate Civil penalty of $500 issued as a result of violation.
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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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2021
LIC809 (FAS) - (06/04)
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