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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700157
Report Date: 04/15/2024
Date Signed: 04/15/2024 12:50:52 PM

Unfounded


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
02/08/2024 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20240208124237
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: 29DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator, Maria Susie DizonTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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9
Staff did not keep the facility clean and sanitary.
Staff did not provide a clean mattress for the resident .
Staff illegally evicting resident.
Staff threatened to resident in care.
Staff do not treat resident with dignity or respect.
Staff did not prevent residents from harassing another resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/15/24 to deliver complaint findings for the above allegations. 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....
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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-20240208124237
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: 04/15/2024
NARRATIVE
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**Report continued from 9099......
Allegation- Staff did not keep the facility clean and sanitary. Staff did not provide a clean mattress for the resident.-UNFOUNDED

LPA conducted a facility tour on 03/07/24, which included 5 resident’s rooms, medication room, and common living spaces at the facility. LPA observed that the facility was clean, safe, and sanitary and odor free. LPA interviewed staff, and all staff stated the housekeepers keep the facility clean and are cleaning daily. LPA interviewed 4 residents in care in which they stated the facility is always clean and did not express any issues. LPA checked mattresses for 5 residents and found no concerns. Staff and resident’s interviews did not indicate any problems with clean mattress for residents. Due to the information gathered, LPA finds these allegations to be UNFOUNDED.

Allegation- Staff illegally evicting resident.-UNFOUNDED

During this investigation, LPA conducted records review, staff and resident’s interviews. LPA found the facility to be compliance with Title 22, 87224 Eviction Procedures for resident, R1. Based on interviews conducted, the preponderance of evidence standards have not been met. Based on information obtained during the investigation, LPA find this allegation to be UNFOUNDED.

Allegation- Staff threatened to resident in care. Staff do not treat resident with dignity or respect. Staff did not prevent residents from harassing another resident in care.- -UNFOUNDED

LPA Bains interviewed 3 staff and 4 residents during complaint investigation on 03/07/24. The department conducted the investigation into the stated allegation from this complaint. The department conducted a tour of the facility on 03/07/24 and conducted interviews with residents and staff. Interviews did not indicate any residents, staff and/or witness observed that staff are not providing dignity and respect to residents in care. During residents’ interviews, residents stated that facility staff are meeting their care needs and did not express any concerns with privacy or dignity. Residents’ interviews indicated that staff were treating all residents with dignity and respect and did not express any issues. Resident’s interviews did not any indications of any harassment and/or threat by staff to residents in any manner and they verbalized that they feel safe there. Based on facility tour, interviews and observation, the department found this allegation is to be UNFOUNDED.

We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and copy of the report was provided at the end.

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

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 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
02/08/2024 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20240208124237

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: 29DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator, Maria Susie DizonTIME COMPLETED:
01:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident's personal items.
Staff did not give resident a copy of their Admission Agreement.
Staff denied shower assistance to resident in care.
Staff did not provide proper medication assistance to resident in care.
Staff did not provide comfortable accommodations to resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/15/24 to deliver complaint findings for the above allegations. 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: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20240208124237
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: 04/15/2024
NARRATIVE
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***Report continued from 9099-A......

Allegation- Staff did not safeguard resident's personal items.-UNSUBSTANIATED

Based on interview statements obtained, the department determined that there were insufficient statements. Statements obtained from staff and residents indicate that there were no known incidents where resident’s personal belongings were being mishandled or mistreated. Statements indicate that staff members ask for permission when handling or moving resident’s belongings prior. RP could not be reached to verify the details of the allegations. Based upon the information obtained during investigation. The above allegations are unsubstantiated.


Allegation- Staff did not give resident a copy of their Admission Agreement.-UNSUBSTANIATED

During this investigation, LPA conducted records review, staff and resident’s interviews. Record review and Staff interviews indicated that admission agreement was prepared for resident, R1 on 12/15/23 upon R1s admission to the facility however R1 refused to sign the admission agreement despite staff attempted several times. Record review indicated that there was a admission agreement copy in R1s file but not signed by R1. The department got conflicting statements regarding this matter and was unable to decide which party was telling the truth. Based on this information, this allegation is found to be Unsubstantiated.

Allegation- Staff denied shower assistance to resident in care.-UNSUBSTANIATED

The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During residents’ interviews, residents stated that staff respond to residents needs in a timely manner, however sometimes there is a delay in response due to staff assisting other residents’ needs. Interviews and record reviews indicated that resident’s ADL’s which includes residents showering, incontinence and care needs are met as required and documented accordingly. Residents’ interviews indicated that staff were providing care in a professional manner and did not express any concerns. Furthermore, LPA observed facility found to be clean and odor free during visit on 03/07/24 and residents interviews indicated no issues with care, therefore this allegation is found to be UNSUBSTANTIATED.

**Report continued on 9099-C....

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

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240208124237
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: 04/15/2024
NARRATIVE
1
2
3
4
5
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***Report continued from 9099-A.....

Allegation- Staff did not provide proper medication assistance to resident in care.-UNSUBSTANIATED

Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During these interviews, it was revealed that the facility dispensed all residents' medications on time and administered them as scheduled. Residents interviews indicated that staff were assisting them with their medications without any issues. Furthermore, a review of the records for the months of January and February 2024, indicated that the facility maintained a proper logs for all medications in the centrally stored medication log, following physician's orders, and documenting them in the Medication Administration Record (MAR) without any errors. Based on these findings, this allegation is considered unsubstantiated.

Allegation- Staff did not provide comfortable accommodations to resident in care. -UNSUBSTANIATED

The department reviewed records, staff, and resident’s interviews to investigate this allegation. Staff interview indicated that there were no issues with temperature at facility and residents were capable to adjust it per their choice. Resident’s interviews indicated that there were no issues with temperature at facility and they were comfortable. In addition to this, the house was at a temperature that is within the acceptable range as per Title 22 Regulations. As per Title 22, Section 87303(b)(2) Maintenance and Operation: The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. During visit on 03/07/24, LPA found the temperature between this required above range. Therefore, the allegation is Unsubstantiated.

Based on this information the department finds all above allegations to be UNSUBSTANTIATED a finding of unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.


Exit interview conducted and copy of report was provided.

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

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5