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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 09/01/2020
Date Signed: 02/10/2021 08:40:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:RIDOLFI, ELEINAFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 79DATE:
09/01/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jade ParkerTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted a case management tele-visit on 9/1/2020. LPA spoke to Jade Parker, Administrator, and explained the purpose of the phone.

Licensing Program Analyst (LPA) Albert Johnson conducted a case management tele-visit on 9/1/2020. LPA spoke to Jade Parker, Administrator, and explained the purpose of the phone.

LPA reviewed the incident report for R1 dated 8/31/2020. The facility reported that on 8/30/2020, (R1) reported to Med tech (MT-Stephanie Vatsula) that a staff (S1- Sheryl Hovis) was holding R1's hands down while changing R1, this caused a discoloration of R1's hands and wrist. S1 voluntarily resigned on 9/4/2020 and the final check was sent out on 9/8/2020. This incident was reported to Community Care Licensing and the Ombudsman. There was not an investigation completed, the staff resigned, and the facility did not follow through with an investigation. The Administrator (Jade Parker) did not provide any substantial information. The information provided was the minimal amount reported and recorded. The Med tech did not witness the event. The resident reported the event on 8/30/2019 at 9:20 pm on the evening shift to the Med tech

Based on the information reviewed and interviews conducted S1 violated the personal rights of R1, by holding R1 hands and wrist causing discoloration.

The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/01/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2020
Section Cited

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Personal Rights 80072 (a) (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement has not been met as evidenced by:
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Based on interviews and record review, S1 did not comply with the regulation cited above causing injury to R1 which poses an immediate health and safety and personal rights risk to clients in care.
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S1 was terminated as a result of the facility's investigation.

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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: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2020
LIC809 (FAS) - (06/04)
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