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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 06/09/2021
Date Signed: 06/09/2021 11:28:58 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
05/07/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20210507163932
FACILITY NAME:STACIE'S CHALET STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:KARON MILLSFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 53DATE:
06/09/2021
UNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Karon Mills, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility is not staffed to provide appropriate care and supervision leading to resident fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced complaint visit at the facility and met with Administrator Karon Mills to discuss and complete this complaint investigation. LPA informed Administrator of the purpose for this visit. LPA provided findings regarding the allegation listed above. The investigation was conducted and consisted of reviews of resident records and other facility records. Interviews with facility Administrator, and 6 residents was also conducted.
The complaint alleges that facility is not staffed to provide appropriate care and supervision leading to a resident fall. The investigation was based on interviews and record reviews that it was determined that a staff member who was scheduled to work on a shift in which a resident fell, was not working that shift and was not replaced leading to a shorter than normal staffing schedule. Furthermore, it was determined through interviews that the normal staffing schedule is designed to meet the needs of the residents in care. Based on the interviews and record reviews conducted for this investigation, the above allegation is determined to be SUBSTANTIATED. Deficiencies were cited based on Title 22, Division 8.
A copy of this report was left with Administrator along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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-20210507163932
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: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2021
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care…This requirement was not met as evidenced by:
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Administrator to devise and provide a staffing schedule adequate to meet the current needs of residents. Administrator to submit to LPA by POC due date.

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Based on interviews and record reviews, Licensee did not ensure adequate and sufficient staffing levels during a night shift in which R1 sustained a fall. This poses an immediate health and safety risk to residents in care.
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Administrator to provide a written plan including a line of communication plan designed to prevent staffing shortages. Plan to be submitted to LPA by POC due date.
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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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2