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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 04/27/2021
Date Signed: 04/27/2021 06:53:28 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
01/26/2021 and conducted by Evaluator Ashley Boothe
COMPLAINT CONTROL NUMBER: 27-AS-20210126092010
FACILITY NAME:STACIE'S CHALET STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:PARKER, JADEFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: ZIP CODE:
95204
CAPACITY:114CENSUS: 54DATE:
04/27/2021
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Karon MillsTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident was not provided a copy of rental agreement upon admission
Licensee is unavailable to resident's concerns and their basic needs
Licensee is not providing required house keeping once a week
Resident missed medications
INVESTIGATION FINDINGS:
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On 4/27/21 at 2:45pm Licensing Program Analyst (LPA) Ashley Boothe contacted Administrator on record as of 4/8/2021 Karon Mills and stated the purpose of the visit to deliver the findings of a complaint investigation with the allegations: Resident was not provided a copy of rental agreement upon admission, licensee is unavailable to resident's concerns and their basic needs., licensee is not providing required house keeping once a week, and resident missed medications. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 54.

During the investigation LPA conducted interviews, reviewed records and conducted inspections. Facility staff were unable to locate Resident one (R1’s) admissions agreement in R1’s resident record or and electronic copy for LPA review or provide to R1 upon request. R1’s level of care assessment includes all inclusive laundry, weekly housekeeping, and sheets changed weekly.

Continued on 9099 C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
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 4
Control Number 27-AS-20210126092010
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: 04/27/2021
NARRATIVE
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Continued from 9099.

During the time of the COVID outbreak the facility was short staffed with medical technicians, caregivers, dietary, and housekeeping staff. Housekeeping staff missed weekly housekeeping. R1’s January 2021 MAR noted several instances of medications not administered as physician’s order and no notes R1 refused assistance. No missed medications observed in December 2020. R1’s physician’s report states R1 can administer their own medications and R1 has removed all medications from centrally stored medications room.

During interviews family and responsible parties stated that during communications staff have observed to not communicate effectively. R1 stated staff consistently do not communicate to meet residents’ needs according to basic services provided by the facility. Resident two R2's responsible party stated staff did not report a change in medical condition as R2 was not reported COVID positive. Resident three (R3) POA stated they were not notified of R3's falls.

Based on information obtained the aforementioned allegations are SUBSTANTIATED. A finding that the complaint is substantiated means the preponderance of evidence standard has been met, therefore the allegation(s) is found to be substantiated.

Deficiencies are being cited per Title 22 Regulations. Exit interview was conducted with Karon. Copy of the report was sent to via e-mail with a "read receipt" to verify the LIC 9099, 9099 C, 9099 D and Appeal Rights were received. Karon is to print out the report and fax signed copies to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20210126092010
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: 04/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2021
Section Cited
CCR
87465(a)(5)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (5)The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidence by:
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The licensee agrees to submit a plan to be in compliance with this regulation at all times by POC due date of 4/29/2021. Written declaration to be submitted by fax to LPA at (916)263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
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 Based on records reviewed and interviews the licensee did not ensure a plan to assist residents medication administration as needed. R1’s January 2021 MAR noted several instances of medications not administered as physician’s order which poses an immediate health and safety risk to residents in care.
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Type A
04/29/2021
Section Cited
CCR
87464(f)(1)
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Basic Services(f)Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidence by:
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The licensee agrees to submit a plan to be in compliance with this regulation at all times by POC due date of 4/29/2021. Written declaration to be submitted by fax to LPA at (916)263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
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Based on records reviewed, observation, and interview the licensee did not provide care and supervision to residents in care. During COVID outbreak the facility was short staffed and unable to provide basic care which poses an immediate 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) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210126092010
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: 04/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2021
Section Cited
CCR
87507(e)
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Admission Agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement...The licensee shall provide additional copies to the resident or resident’s representative upon request. This requirement is not met as evidence by:
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The licensee agrees to submit a plan to be in compliance with this regulation at all times by POC due date of 5/6/2021. Written declaration to be submitted by fax to LPA at (916)263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
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Based on records review and interview the licensee did not provide the resident an additional copy of R1’s admissins agreement. R1’s admissions agreement was not retained in the facility which poses a potential health and safety risk to residents in care.
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Type B
05/06/2021
Section Cited
CCR
87464(d)
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Basic Services (d) a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal ... and providing the other basic services. This requirement is not met as evidence by:
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The licensee agrees to submit a plan to be in compliance with this regulation at all times by POC due date of 5/6/2021. Written declaration to be submitted by fax to LPA at (916)263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
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 Based on records reviewed, observation and interview the licensee did not meet the needs as identifiyed in the pre-admission appraisal. R1 was not provided weekly housekeeping, laundry and sheet’s changed 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) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4