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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 06/17/2022
Date Signed: 06/17/2022 12:28:28 PM

Substantiated


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
01/21/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220121111716
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:0CENSUS: 0DATE:
06/17/2022
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Report mailed to previous LicenseeTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not obtain timely medical care for a resident with a COVID diagnosis who died at the facility.
Staff did not notify authorized representative of resident COVID diagnosis.
Staff was unqualified to care for the resident.
INVESTIGATION FINDINGS:
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On 6-17-22 at 10:33am, Licensing Program Analyst (LPA) Michael Bilger completed findings for the complaint allegations noted above. Throughout this investigation, LPA interviewed complainant and staff1 (S1), a previous staff member of this facility which closed effective 7-1-21. LPA also reviewed death certificate for resident1 (R1), death report for R1, and additional evidence. R1s previous record was not obtainable due to facility closure. LPA attempted to locate R1s record during visits on 1-24-22, 5-24-22, and with assistance from S1. A subpoena was filed in attempt to recover R1s file but was unsuccessful.

Allegation #1: Staff did not obtain timely medical care for a resident with a COVID diagnosis who died at the facility. LPA reviewed death certificate for R1 and conducted interviews with S1 and complainant. LPA also reviewed additional evidence. Based on interviews and record reviews it was determined that R1 obtain a COVID diagnosis on 1-12-21 in which during a time frame from 1-12-21 to 1-20-21 R1 did not receive timely medical care due to a staffing shortage and unqualified staff members attending to needs of R1. {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: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
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 6
Control Number 27-AS-20220121111716
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: 06/17/2022
NARRATIVE
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 It was further determined that R1 passed away due to COVID-19 on 1-20-21. Additionally, a previous substantiated allegation from a complaint generated on 1-26-21 revealed a citation issued to licensee on 4-27-21 due to staffing shortage and lack of basic care provided during a COVID outbreak occurring within close proximity to the time frame mentioned above regarding this allegation. Based on the interviews and record reviews for this investigation, this allegation is SUBSTANTIATED.

Allegation #2: Staff did not notify authorized representative of resident COVID diagnosis. LPA conducted interviews with S1 and complainant and conservator for R1. LPA also reviewed death report and death certificate for R1, and additional evidence. Based on interviews and record reviews, it was determined that conservator for R1 and Son for R1 was not notified of R1s COVID-19 diagnosis which occurred on 1-12-21. Based on the interviews and record reviews, this allegation is SUBSTANTIATED.

Allegation #3: Staff was unqualified to care for the resident. LPA conducted interviews with S1, complainant and reviewed additional evidence. Based on interviews and record reviews, it was determined that due to a staffing shortages and COVID-19 outbreak between 1-12-21 and 1-20-21, the maintenance director was assisting with several positions within the facility including observation and supervision of R1. Based on interviews, it was determined that maintenance director was not qualified to conduct observation and supervision of R1. As a result, this allegation is SUBSTANTIATED.

Citations are issue under Title 22, Division 6. Due to facility closure, A copy of this report will be mailed to Licensee with a request for return with signature. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20220121111716
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: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2022
Section Cited
CCR
87464(f)(1)
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Basic Services(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).
This requirement is not met as evidence by:
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Facility is no longer in operation
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 Based on interviews and additional evidence, the licensee did not provide appropriate levels of care and supervision to residents in care. During a COVID-19 outbreak, an unqualified staff member provided supervision of residents due to a staffing shortage. This poses an immediate health and safety risk to residents in care.
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Type A
06/20/2022
Section Cited
CCR
87411(a)
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Personnel Requirements-General. 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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Facility is no longer in operation
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 Based on interviews and additional evidence, a staffing shortage occurred during a COVID-19 outbreak and an unqualified staff (maintenance director) provided care and supervision for R1. This poses an immediate health and safety 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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20220121111716
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: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2022
Section Cited
CCR
87211(a)(1)(D)
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7
Reporting Requirements. (a)Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted…to the person responsible for the resident…within seven days of the occurrence…(D) Any incident which threatens the welfare, safety or health of any resident…This requirement is not met as evidenced by:
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Facility is no longer in operation
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 Based on interviews and additional evidence, licensee did not ensure timely reporting of R1’s COVID-19 diagnosis to responsible person. This poses an immediate health, safety, and resident 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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/21/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220121111716

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:0CENSUS: 0DATE:
06/17/2022
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Report mailed to previous LicenseeTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
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9
Dental Hygiene not provided.
Foot care not provided.
INVESTIGATION FINDINGS:
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On 6-17-22 at 10:33am, Licensing Program Analyst (LPA) Michael Bilger completed findings for the complaint allegations noted above. Throughout this investigation, LPA interviewed complainant and staff1 (S1), a previous staff member of this facility which closed effective 7-1-21. LPA also reviewed death certificate for resident1 (R1), death report for R1, and additional evidence. R1s previous record was not obtainable due to facility closure. LPA attempted to locate R1s record during visits on 1-24-22, 5-24-22, and with assistance from S1. A subpoena was filed in attempt to recover R1s file but was unsuccessful.

Allegation: Dental hygiene not provided. LPA conducted interviews with S1 and complainant, and reviewed death certificate for R1 as well as additional evidence. Based on interviews and record review, it was determined that R1 passed away due to COVID-19 on 1-20-21 and complaint was received on 1-21-22. Evidence reviewed by LPA did not specifically determine a lack of dental hygiene. As a result, there is not a preponderance of evidence to prove dental hygiene was not provided to R1. Therefore this allegation is UNSUBSTANTIATED.

{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20220121111716
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: 06/17/2022
NARRATIVE
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5
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7
8
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Allegation: Foot care not provided. LPA conducted interviews with S1 and complainant, and reviewed death certificate for R1 as well as additional evidence. Based on interviews and record review, it was determined that R1 passed away due to COVID-19 on 1-20-21 and complaint was received on 1-21-22. Evidence reviewed by LPA did not specifically determine a lack of foot care. As a result, there is not a preponderance of evidence to prove foot care was not provided to R1. Therefore this allegation is UNSUBSTANTIATED.

A copy of this report will mailed to licensee with a request for return with signature.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6