392700361-4-27-2021-27-AS-LKIG-C2JSAT-20210429134252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 04/27/2021
Date Signed: 04/27/2021 07:01:28 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
01/20/2021 and conducted by Evaluator Ashley Boothe

COMPLAINT CONTROL NUMBER: 27-AS-20210120125511

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: 54	DATE:	04/27/2021
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Karon Mills		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility is not responding to residents care needs
Facility phones are in disrepair

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: Facility phones in disrepair and facility is not responding to residents care needs. 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 reviewed records and conducted interviews. Based on interview the facility phones in the office not in working order and staff have turned the ringer to a lower volume on working phones. During the time the facility experienced a COVID outbreak there was not enough staff to meet the needs of the residents and their needs surpassed the necessity of answering the phone.

Continued on 9099 C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (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)

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Control Number 27-AS-20210120125511

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.

Resident one (R1’s) admissions agreement states facility will secure appointments and provide transportation to medical and dental appointment within a 10 mi radius of facility. The transportation company used from 11/27/2020 to transport R1 to dialysis three times weekly as directed by physician’s order does not transport COVID positive residents. The facility did not provide transport in the facility bus or arrange for alternate transportation to provide R1 transport to medical appointments when R1 was reported COVID positive. R1 missed scheduled medical appointments on twice in January 2021 before they were transferred to hospital.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (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)

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Control Number 27-AS-20210120125511

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)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(2)... This includes transportation ... the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidence by:	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	Based on record review and interview the licensee did not provide direct transportation or make arrangements to medical appointments. R1 missed dailysis appointments on 1/18/2021 and 1/20/2021 which poses an immediate health and safety risk to residents in care	8 9 10 11 12 13 14
Type B 05/06/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by:	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	Based on record review and interview the licensee did not ensure the facility was in good repair. S1 stated facility phones are not in working order which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (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)

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