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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 06:39:30 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
02/22/2021 and conducted by Evaluator Ashley Boothe
COMPLAINT CONTROL NUMBER: 27-AS-20210222155029
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: 54DATE:
04/27/2021
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Karon MillsTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident had multiple falls while in care.
Staff do not meet resident's hygienic care needs.
Staff do not safeguard resident's personal property.
Staff do not communicate effectively.
INVESTIGATION FINDINGS:
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On 4/27/2021 at 2:45pm Licensing Program Analyst (LPA) Ashley Boothe contacted Administrator of 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 had multiple falls while in care, staff do not meet resident's hygienic care needs, staff do not safeguard resident's personal property, and staff do not communicate effectively. 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 Resident One (R1)’s resident file including discharge instructions from Hospital for unwitnessed falls on 11/9/2020 and 12/13/2020 where R1 suffered injury. R1’s LIC 602 and preappraisal state R1 requires assistance while toileting and cannot get in and out of wheelchair without assistance. Staff responsible for R1’s care stated they were not notified of R1’s fall risk before providing R1 care. R1’s Power of Attorney (POA) stated falls were not reported to them by facility staff.
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-20210222155029
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.

Staff stated the facility was short staffed of housekeepers, caregivers, medical technicians during COVID outbreak and there were not enough staff to meet the care needs of the residents. Staff stated R1 has gone over a week without bathing. LPA reviewed 4 pages of personal property logs completed by POA on 6/26/2020. R1 was moved out of their room during COVID isolation for a in January 2021. During interviews Resident two (R2) and Resident three (R3)'s responsible party stated multiple items missing during room changes and while staff conducted laundry services. During interviews family and responsible parties stated that during communications staff have observed to not communicate effectively. R2 stated staff consistently do not communicate to meet residents’ needs according to basic services provided by the facility. R3's responsible party stated staff did not report a change in medical condition as R3 was not reported COVID positive.

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-20210222155029
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
87466
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Observation of the Resident: ... residents are regularly observed for changes in physical, mental, emotional and social functioning...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person. 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 record review and interview the licensee did not ensure responsible parties were notified of residents changes in conditions. R1 and R2's responsible parties were not notified of changes in physical condition 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(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 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 record review and interview the licensee did not ensure residents needs were met based on their preadmission appraisal. Staff were not notified of R1’s need for assistance and fall risk 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-20210222155029
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
87464(f)(4)
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Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed ... such as dressing, eating, bathing and assistance with taking prescribed medications. 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 record review and interview the licensee did not ensure residents were provided assitance with bathing. S1 stated R1 missed 3-4 showers in a six week period which poses an potential health and safety risk to residents in care.
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Type B
05/06/2021
Section Cited
CCR
87218(a)
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Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153.
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 record review and interview the licensee did not ensure an adequate theft and loss program. Interviews stated multiple instances of missing items during room changes and laundry service which poses an 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