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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700157
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:48:51 PM


Document Has Been Signed on 01/30/2024 12:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CHALET, THEFACILITY NUMBER:
342700157
ADMINISTRATOR:SUSIE DIZONFACILITY TYPE:
740
ADDRESS:6487 MAIN STREETTELEPHONE:
(925) 787-2740
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:41CENSUS: 26DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Susie DizonTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Talwinder Bains and Melissa Parks arrived on Tuesday January 30, 2024 to conduct the unannounced annual inspection.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (12) and staff (5) files. LPAs did not observe current needs and service plans for 11 out of the 12 resident files reviewed. All staff files contained the required paperwork and training.

LPAs and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included apartments, bathrooms, kitchen, dining room, common areas, laundry room, and backyard. Facility has a full supply of PPE. First Aid kit was fully stocked. All water temperatures were within the required range. In the areas toured, there were no health or safety violations observed.

LPAs requested the following documents to be sent to the Department: current liability insurance, updated LIC610E and LIC500 by 02/15/24.

See 809-D for deficiency cited per Title 22 regulations . Exit interview conducted. A copy of this report and appeal rights were email to administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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Document Has Been Signed on 01/30/2024 12:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CHALET, THE
FACILITY NUMBER: 342700157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 11 out of 12 resident files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Administrator will update/complete needs and services plans for all residents. Administrator will notify LPA Bains via email when completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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