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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700157
Report Date: 10/04/2023
Date Signed: 10/04/2023 11:17:14 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20231003115708
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:
10/04/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Susie Dizon TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff do not provide assistance in a timely manner.
INVESTIGATION FINDINGS:
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On 10/04/23, LPA Bains came to the facility to do complaint investigation on above allegation. LPA was screened upon entry including temparature. LPA met with administrator, Maria Susie Dizon and explained the purpose of the visit.

Throughout the course of the investigation the department did facility observations and conducted interviews with residents and staff relevant to the complaint allegation.



Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 59-AS-20231003115708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/04/2023
NARRATIVE
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Report continued from LIC9099........


Allegation- Staff do not provide assistance in a timely manner.

The department conducted residents and staff interviews and facility observations to investigate the complaint allegation. During facility observations, it has been revealed that R1 has no Call Button to use in their room and facility did not provide any other alternative way so R1 can call staff if they need any assistance with thier care needs. Furthermore, residents and staff interviews indicated that facility were not accepting any calls form R1s phone as their number has been 'restricted' but facility has no explanation what was the reason behind that. Residents interview indicated that R1 has to ask thier room mate help if R1 need any assistance since only R1s room mate has access to call button. Facility observations indicated that if R1s room mate is out from room , R1 has no other way to call for help as R1 needed. Based on all the information, this allegation - Staff do not provide assistance in a timely manner has been SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The deficiency is cited on 9099-D, per Title 22 Regulations, Division 6.


Exit interview conducted with administrator. . Appeals rights provided. Copy of the report left at the facility.







SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20231003115708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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Administrator shall ensure that R1 and all other residents have access to working Call Button at all times. Administrator will submit letter of understanding of this regulation and will train all staff as well and send all records to CCL by POC date by 10/05/23.
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Based on obsevations and interviews conducted, the facility did not ensure that R1 has access to call button so R1 can call when R1 need assistance from staff which poses a Immediate health, safety, and personal rights 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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20231003115708

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:
10/04/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Susie Dizon TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff left resident in soiled diapers.
INVESTIGATION FINDINGS:
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On 10/04/23, LPA Bains came to the facility to do complaint investigation on above allegation. LPA was screened upon entry including temparature. LPA met with administrator, Maria Susie Dizon and explained the purpose of the visit.

Throughout the course of the investigation the department did facility observations and conducted interviews with residents and staff relevant to the complaint allegation.



Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20231003115708
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/04/2023
NARRATIVE
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Report continued from LIC9099........


Allegation- Staff left resident in soiled diapers.

Department interviewed 3 staff and 2 residents during complaint investigation.The department conducted interviews, facility observation and record review to investigate above allegation. During interviews with facility staff and residents, it has been revealed that facility is providing care to residents according to resident’s needs and service plans. During residents’ and staff interviews, it has been concluded that facility has enough staff to meet the needs of the residents in care. Furthermore, there were some residents who required more care than others and those residents call staff every 15-20 minutes and staff tried their best level to assist all residents care needs but Not leaving any residents in their soiled diapers for extended durations, therefore, the above allegation is found to be UNSUBSTANTIATED.

A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.



Exit meeting conducted with administrator.
A copy of this report has been provided to facility.









SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5