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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 12/07/2020
Date Signed: 12/07/2020 11:20:29 AM



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
08/24/2020 and conducted by Evaluator Ruth Wallace
COMPLAINT CONTROL NUMBER: 27-AS-20200824161944
FACILITY NAME:STACIE'S CHALET STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:RIDOLFI, ELEINAFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 76DATE:
12/07/2020
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Telephone Call - COVID Precautions/Administrator Jade ParkerTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility staff did not give medications as prescribed to Residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Wallace contacted the facility on this day via telephone to conclude a complaint investigation due to COVID-19 and pre-cautionary measures. A physical visit was not conducted in that the Department is not conducting Residential Care for the Elderly visits at this time, due to the COVID-19 virus. LPA spoke with Administrator (AD) Jade Parker and explained the purpose of the visit.

On August 24, 2020 Community Care Licensing received a Complaint with the allegation: Facility staff did not give medications as prescribed to residents (R1). Three medications were: Metformin 1000mg, Carbidopa 25-100mg, and Duloxetine 30mg.

Medications not given as prescribed by physician to R1’s routine medications at 6:00 am, 8:00 am, and 8:00 PM between August 7-27, 2020 were: Metformin 1000mg, Carbidopa 25-100mg, and Duloxetine 30mg.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
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
Control Number 27-AS-20200824161944
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: 12/07/2020
NARRATIVE
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Continued from 9099

LPA reviewed nursing nurse’s medication notes, medication assistance record, prescribed as needed medications, interviewed staff, resident, and resident’s daughter. The documentation obtained and reviewed did show that medications were missed and there is no record of the medications being received from pharmacy.

LPA reviewed all documents provided, interviewed staff, Administrator, Resident Care Director, Resident, and Family Member. The staff, Administrator, and Resident Care Director stated that medications were not given to R1 based on nurse’s medication notes, medication assistance record, and no Centralized Medication Record for R1 for the month of August 2020. Based on the documentation provided and acknowledgement of the facility, the complaint regarding
facility staff not giving medications as prescribed to residents is SUBSTANTIATED. There was a preponderance of evidence to prove that the incident occurred as reported.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Jade Parker and a copy of 9099, 9099-C, 9099-D, and Civil Penalty Will Be Assessed Second Violation of Deficiency within one year were provided along with 811- Confidential Names List, and appeal rights via email. An electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20200824161944
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: 12/07/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/08/2020
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care - 87465(c)(2)
Once ordered by the physician the medication is given according to the physician's directions.
The Licensee did not ensure the health and safety of residents which poses an immediate health and safety risk to residents in care.
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Administrator agrees to submit a plan stating how Resident (R1’s) medications will be given according to the physician’s directions by 12/8/2020. Administrator can submit via email to LPA Ruth Wallace.
ruth.wallace@dss.ca.gov
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This requirement was not met as evidenced by: Based on LPA’s documentation reviewed and interviews R1 was not administered the following medications: Metformin 1000mg, Carbidopa 25-100mg, and Duloxetine 30mg.
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Type B
12/21/2020
Section Cited
CCR
87465(h)(6)(A)
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Incidental Medical and Dental Care - 87465 (h)(6)(A
The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(A) The name of the resident for whom prescribed.

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Licensee agrees to submit a written plan of correction for second deficiency within the year for the same regulation. Administrator will submit plan of correction via email by 12/21/2020 to LPA by on how to be in compliance with the regulation 87465(i) at all times.
ruth.wallace@dss.ca.gov

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Based on interview with R1, staff, and record review with Administrator the Licensee did not comply with the regulation cited above 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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20200824161944
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: 12/07/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2020
Section Cited
CCR
87506(b)(8)
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Resident Records - 87506(b)(8)
Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency.
LPA interviewed daughter of R1 and it was determined that she was never notified of medications being missed from August 7-27, 2020. No documentation or incident reports submitted to Community Care Licensing either.
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Administrator agrees to submit a written plan of correction for second deficiency within the year for the same regulation. Administrator will submit via email by 12/21/2020 plan of correction to LPA by on how to be in compliance with the regulation 87506 (b)(8) at all times.
ruth.wallace@dss.ca.gov
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Based on interview of resident’s representative the facility did not notify representative regarding the missed medications. The Licensee did not comply with the regulation cited above 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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4