392700361-3-4-2021-27-AS-KHOS-BYZPCN-20210311101212

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 03/04/2021
Date Signed: 03/04/2021 04:51:44 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
11/17/2020 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201117141739

FACILITY NAME:	STACIE'S CHALET STOCKTON		FACILITY NUMBER:	392700361
ADMINISTRATOR:	PARKER, JADE		FACILITY TYPE:	740
ADDRESS:	517 E FULTON ST		TELEPHONE:	(209) 466-2116
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	114	CENSUS: 71	DATE:	03/04/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Maria Cantoria and Jade Parker		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility equipment is in disrepair.
Resident is not being provided with a Hoyer Lift.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Johnson conducted a call to the facility regarding the complaint investigation with the above allegations. LPA talked with Administrator and explained the purpose of today's call to deliver investigation findings.

Allegations: Facility equipment is in disrepair and Resident is not being provided with a Hoyer Lift. Based on records reviewed and interviews by LPM KIng on 1/5/2021 with Resident Service Director and LPA Johnson's interview with Resident Services Director on 12/9/2020 the facility did not meet the needs of R1, the facility failed to provide necessary equipment required to assist R1 with incontinence and other care.

Continued

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2021

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-20201117141739

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: 03/04/2021

NARRATIVE

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R1 had not been seen by home health since 11/25/2020 and there has been no follow-up per discharge orders from the 11/19/2020 ER visit to R1's primary care physician. This information was observed in R1's facility file on LPA Johnson inspection dated 12/05/2020.

LPM King confirmed on 1/5/2021, during a Tele-visit with the facility that Resident Services Director (Joel Toeldo) that that hoyer lift is brokenand only one staff was able to use it. That staff is and has not been present. When LPM King asked how Joel knows it does not work, Joel responded that it is confirmed not to work and a new hoyer lift has been approved by the residents insurance company (sometime in November he thinks) however, resident does not have the funds to purchase a sling. Joel went on to explain that he had applied for a waiver due to financial hardship with "Supercare" in November and has not heard anything back. He further went on to state that he needs to follow up. Joel confirmed that the resident has not been out of bed for "months" due to staffs inability to transfer him.

As a result of this investigation, the Department finds the allegations to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview was conducted with Licensee where LPA reviewed report. An electronic copy of the report was emailed to the facility to obtain a signature from the Licensee and emailed back to LPA to be filed.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20201117141739

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: 03/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/05/2021 Section Cited CCR 87468(a)(2)	1 2 3 4 5 6 7	87468(a)(2) Personal Rights. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility will repair, replace or get a new Hoyer lift by POC date 3/5/2021
	8 9 10 11 12 13 14	LPA's review of records, interviews conducted and observation. The facility has not provided R1 with the medical equipment needed to meet R1's needs. This is an immediate health and safety concern.	8 9 10 11 12 13 14
CCR	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

LIC9099 (FAS) - (06/04)

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