392700361-10-5-2020-27-AS-LKIG-BUBR4L-20201012124142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 10/05/2020
Date Signed: 10/05/2020 04:37:31 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
02/12/2020 and conducted by Evaluator Diego Escobar

COMPLAINT CONTROL NUMBER: 27-AS-20200212094703

FACILITY NAME:	STACIE'S CHALET STOCKTON		FACILITY NUMBER:	392700361
ADMINISTRATOR:	PETERSON-WORLEY, ALESIA		FACILITY TYPE:	740
ADDRESS:	517 E FULTON ST		TELEPHONE:	(209) 466-2116
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	114	CENSUS: 81	DATE:	10/05/2020
		UNANNOUNCED	TIME BEGAN:	04:06 PM
MET WITH:	Jade Parker, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Timely medical attention was not sought for resident
Staff yells at residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Diego Escobar made a subsequent complaint investigation televisit on 10/05/2020. LPA spoke to Jade Parker, Administrator, and explained the purpose of the call.

The department conducted interviews and record reviews. Resident 1 (R1)'s medical records and death certificate were obtained. Details in the reports indicate there was no evidence of a questionable death or anything suspicious. Staff interviews do not support the allegations listed above.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted with Jade. Copy of the report sent to Jade via e-mail with a "read receipt" to verify the LIC 9099 was received. Jade is to print out the report, and fax a signed copy to LPA at 916-263-4744.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego Escobar	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2020

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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