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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 03:37:23 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
10/15/2020 and conducted by Evaluator Diego Escobar
COMPLAINT CONTROL NUMBER: 27-AS-20201015162321
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, Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not assist resident with transportation needs
Facility staff did not notice a change in the resident's condition
Facility staff did not assist resident with hygiene needs
Facility staff did not ensure that resident had clean clothing
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.

On 10/14/2020 Resident 1 (R1) arrived to his day program with urine on his clothing. Nurse at the Day Program charted "10/14/20...it was also noted that ptp had strong odor of urine." Through anonymous interviews, it was confirmed that R1 left the facility wet in urine to his Day Program and it was sated to LPA that R1's care plan is not accurate and R1 needs a lot of assistance with toileting and ambulating. Current care plan indicates R1 is independent with toileting, ambulation, meals and needs stand by assist with transfers, dressing, and bathing/grooming. R1's care plan indicated R1 needs total assist with medical, dental, and psychiatric appointments "Assist client with transportation to appointments." No records show that the facility contacted R1's physician to address the change of condition. 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.
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: 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)
Page: 1 of 4
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
10/15/2020 and conducted by Evaluator Diego Escobar
COMPLAINT CONTROL NUMBER: 27-AS-20201015162321

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, Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff do not allow residents to use their walkers
Facility staff did not seek medical attention in a timely manner
Facility staff is not obtaining resident's medication in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diego Escobar made a subsequent investigation televisit on 11/25/2020 to deliver the allegation findings. LPA spoke to Jade Parker, Administrator, and explained the purpose of the call.

LPA interviewed Administrator, residents, and staff members. Walker was seen in Resident 1 (R1)'s room but R1 did not want to use the walker. A conference meeting was held with R1's care team on 10/19/2020 and R1's walker preference was discussed. R1 was seen by a physician on 10/15/2020. Physician prescribed new medication for R1. Based on record review, R1 was assisted with the new medication as instructed.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted with Administrator. Copy of the report sent to Jade Parker via e-mail with a "read receipt" to verify the LIC 9099 was received. Jade is to print out each report, and fax a signed copy to LPA at 916-263-4744.
Unsubstantiated
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)
Page: 2 of 4
Control Number 27-AS-20201015162321
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: 11/25/2020
NARRATIVE
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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. Citation has already been issued - refer to complaint control number 27-AS-20200925083632.

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-A, LIC 9099-D and Appeal Rights were received. Administrator is to print out each report 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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20201015162321
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
87466
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The licensee shall ensure that residents are regularly observed for changes...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. 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 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 not documenting R1's change of condition and not notifying R1's physician which poses a potential health and safety risk to residents in care.
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Type B
12/02/2020
Section Cited
CCR
87625(b)(3)
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(b)In addition to Section 87611...the licensee shall be responsible for the following:(3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. 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 87625(b)(3) 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 ensuring R1 was clean and dry 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)
Page: 4 of 4