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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 10/28/2020
Date Signed: 10/28/2020 03:28:46 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
and conducted by Evaluator Diego Escobar
COMPLAINT CONTROL NUMBER: 27-AS-20200326124310
FACILITY NAME:STACIE'S CHALET STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:PETERSON-WORLEY, ALESIAFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 80DATE:
10/28/2020
UNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Jade Parker Administrator TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Illegal eviction.
Resident sustained unexplained bruising while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diego Escobar made subsequent complaint investigation televisit on 10/28/2020 to deliver the allegation findings. LPA spoke to Jade Parker, Administrator, and explained the purpose of the visit.

Resident 1 (R1) and their respective responsible party received an eviction letter dated 2/11/2020. Eviction letter has the effective eviction date 3/12/2020. Eviction letter alleges R1 had an increase of verbal aggression and physical altercations between residents and staff. LPA reviewed R1’s care plan dated 1/2/2020 and signed by R1’s responsible party and facility representative on 1/2/2020. R1’s aggression was identified on the care plan and behavior management plan for R1 indicates “Staff will monitor for the reduction of or elimination of triggers and symptoms of behavior” and “report any increase in behaviors to Primary Care Physician.” The eviction letter does not include reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.
...CONTINUES ON LIC 9099-C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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-20200326124310
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: 10/28/2020
NARRATIVE
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...CONTINUED FROM LIC 9099...

LPA reviewed charting notes for R1. On 2/3/2020, R1's relative visited R1 and asked staff about a bruise on R1's left thigh. Staff did not know how R1 got the bruise. LPA obtained photos of said bruise and observed the bruise to be dark purplish in color located on the outer side of R1's thigh. On one photo, R1's hand is seen next to the bruise. From hip to knee direction: the size of the bruise is approximately same size as the resident's hand measured from wrist to fingertips. Memory care staff confirmed R1 had a bruise, but staff did not know how or when R1 got the bruise.


Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated.

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9009, LIC 9099-D, LIC 811 and appeal rights were received. Administrator is to print out the LIC 9009, LIC 9099-D and fax signed copies to LPA at 916-263-4744.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20200326124310
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: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2020
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...This requirement has not been met as evidenced by:
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Licensee agrees to submit a plan of correction to LPA by 10/29/2020 on how the facility will be in compliance with regulation 87466 at all times.
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Based on interviews and record review, the licensee did not comply with the regulation cited above by failing to regularly observe R1 which resulted in R1 obtaining an unexplained bruise which poses an immediate health and safety risk to residents in care.
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Type B
11/06/2020
Section Cited
CCR
87224(d)
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(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.
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Licensee agrees to submit a plan of correction to LPA by 11/06/2020 on how the facility will be in compliance with regulation 87224(d) at all times.
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Based on interviews record review, the licnesee did not comply with the regulation cited above by ... which posses 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) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3