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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 04/08/2021
Date Signed: 04/09/2021 10:00:47 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
12/15/2020 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201215155339
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: 62DATE:
04/08/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maria Cantoria (TM)TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff unable to use proper precautions because they weren’t notified of resident’s condition.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) made several attempts without success starting at 1:20pm to contacted the facility via telephone to deliver findings for this complaint investigation due to COVID-19 and pre-cautionary measures. LPA made contact at 1:43pm with Jade Parker, Jade provided LPA with TM phone number and LPA was able to make contact. LPA identified himself and discussed the purpose of the call and the allegation with theTM/Administrator.

Allegation: Staff unable to use proper precautions because they weren’t notified of resident’s condition. Based on interviews and records reviewed R1 was not diagnosised with MERSA, but had a case of the Shingles. The facility staff was provided with personal protective equipment for care while assisting R1. R1 was sent out to the hospital on 1/7/2021 to have a procedure done on her leg and coded while having this procedure completed. R1 passed on 1/10/2021. Continued
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021
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 2
Control Number 27-AS-20201215155339
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: 04/08/2021
NARRATIVE
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This agency has investigated the allegation listed above. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and report reviewed with Maria Cantoria.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2