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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 11/25/2020
Date Signed: 11/25/2020 03:17:33 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
09/25/2020 and conducted by Evaluator Diego Escobar
COMPLAINT CONTROL NUMBER: 27-AS-20200925083632
FACILITY NAME:STACIE'S CHALET STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:PARKER, JADEFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 78DATE:
11/25/2020
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Jade Parker, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not maintain adequate staffing to meet resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Diego Escobar conducted an subsequent complaint investigation visit on 11/25/2020. LPA met with Jade Parker, Administrator, and explained the purpose of the visit.
LPA reviewed Resident 1 (R1)'s care plan and charting notes. R1's care plan indicated R1 needs total assist with medical, dental, and psychiatric appointments "Assist client with transportation to appointments." R1 had a scheduled doctor's appointment for 10/15/2020. On 10/15/2020, doctor's office could not get a hold of any staff at Stacie's Chalet. R1's Day Program staff discovered that Stacie's Chalet staff could not take R1 to his appointment and Day Program staff decided to provide transportation for R1. Based on LPA's observation, interview and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The following deficiency was 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 was conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099, LIC 9099-D and Appeal Rights were received. Jade is to print out each report and fax a signed copy to LPA at 916-263-4744.
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: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 27-AS-20200925083632
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: 11/25/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2020
Section Cited
CCR
87464(f)(6)
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(f) Basic services shall at a minimum include:
(6) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement has not been met as evidenced by:
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Licensee agrees to submit a written plan of correction to LPA by 12/2/2020 on how the facility will be in compliance with regulation 87464(f)(6) at all times.
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Based on interviews and record review, the licensee did not comply with the regulation cited above by not arranging transportation for R1 on 10/15/2020 as agreed with R1 and R1's responsible party which poses a potential 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: 11/25/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
LIC9099 (FAS) - (06/04)
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