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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:38:13 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20210617142645
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:0CENSUS: 53DATE:
07/07/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Anuradha SainiTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Lack of Care and Supervision

Incontinence care not being provided
INVESTIGATION FINDINGS:
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On 7/7/2021 at 9:15am Licensing Program Analyst (LPA) Michael Bilger arrived unnannounced to deliver findings for the above allegations listed. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. Throughout this investigation a total of 5 residents and 8 staff members were interviewed including Administrator. Facility records were also obtained and reviewed including staffing roster, resident roster, staffing schedule, and actual hours worked. On 6/25/21, 5 residents were interviewed regarding care and supervision as well as incontinence care.

Based on resident interviews, 3 of 5 residents believe staff is not able to meet all their care and supervision needs including incontinent care. Between the dates of of 6/21/21, 6/25/21, 6/30/21, 7/1/21, and 7/7/21, 8 staff members were interviewed. 4 of 8 staff members stated resident care and supervision as well as incontinent care needs are not being met given the current staffing situation. On 6/25/21, Administrator was interviewed by LPA regarding the care and supervision and incontinence care. On 7/7/21, Staff8 (S8) was interviewed by LPA regarding care and supervision and incontinence care. (Cont. on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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 3
Control Number 27-AS-20210617142645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/07/2021
NARRATIVE
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On 7/7/21, LPA reviewed actual hours worked and staffing schedules from 6/1/21 to 6/30/21. Based on these interviews and based on record reviews it was determined that not all scheduled staff was available to meet residents care and supervision and incontinent care needs during the dates of 6/12/21 and 6/13/21 on the night shift. Based on all records reviewed and interviews conducted it is determined that the preponderance of evidence standard has been met, therefore the above allegations are SUBSTANTIATED. Deficiencies were cited today based on Title 22 regulations, Division 8. An exit interview was conducted with Administrator Anuradha Saini. A copy of this report and appeal rights have been left with Anuradha.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210617142645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2021
Section Cited
CCR
87413(a)(1)
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(a) In each facility (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by:
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Licnesee will submit a written plan outlining the steps taken to ensure care and supervision needs are provided. Licensee to submit plan to LPA by POC due date.
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Based on interviews and record reviews, Licensee did not provide appropriate staffing levels necessary to meet the care and supervision for residents in care during the night shift on 6/12/21 to 6/13/21. This poses and immediate health, safety, and resident rights risk to residents in care.
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Type B
07/26/2021
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
(d) "Care and supervision" means the facility assumes responsibility for...ongoing assistance with…personal care.
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Licensee shall submit a written plan to ensure the incontinent needs of resdients are provided. Licensee to submit plan to LPA by POC due date.
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This requirement is not met as evidenced by:

Based on interviews and record reviews, Licensee did not ensure appropriate incontinent care for residents in memory care during the night shift on 6/12/21 to 6/13/21. This poses a potential health, safety, and resident rights risk for 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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3