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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 06/10/2021
Date Signed: 06/10/2021 01:19:36 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
02/10/2021 and conducted by Evaluator Ashley Boothe
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210210152517
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: 53DATE:
06/10/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Karon MillsTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Questionable death
A resident was not taken for dialysis treatments
Licensee did not return representatives phone calls promptly
INVESTIGATION FINDINGS:
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On 6/10/2021 at 11:45am Licensing Program Analyst (LPA) Ashley Boothe conducted an unannounced visit with Administrator Karon Mills and stated the purpose of the visit to deliver the findings of a complaint investigation with the allegations: Questionable death, a resident was not taken for dialysis treatments and licensee did not return representatives phone calls promptly.

During the course of the investigation, the department conducted interviews, reviewed records, and conducted on site inspection. Based on the information obtained the facility experienced a COVID outbreak. Resident one (R1) was observed to be vulnerable to COVID due to underlying medical history. Home Health notes "It is highly recommended that R1 be homebound at all times and be monitored for COVID 19 due to the outbreak in the facility and the increased risk of contracting COVID 19. R1 would have worse symptoms if becomes positive due to the medical history". Facility staff did not follow recommendations from HAI to mitigate COVID spread. R1 was not reappriased by staff to note R1's vulnerability during the time the facility expeirinced a COVID outbreak or when R1 tested positivite for COVID.
Continues 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: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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-20210210152517
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: 06/10/2021
NARRATIVE
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Continued from 9099.

R1’s physicians order of dialysis three times weekly was neglected while R1 was COVID positive. The transportation company used to provide R1 transport was unable to provide transport based on COVID positive status. The facility staff did not provide transportation assistance and R1 missed dialysis appointments for approximately one weeks time. R1’s conditions were not observed by staff, R1 attended a dialysis appointment where blood oxygen levels were low and R1 was provided transport to St. Joseph’s where R1 passed away three days later with cause of death acute respiratory failure, septic shock with sever sepsis, viral pneumonia and COVID 19. Due to R1’s contraction COVID 19 due to the facility’s outbreak and the facility failing to provide proper care, R1 ultimately passed away due to their negligence in care. The facility’s phones have been observed to not be in working order. During the COVID outbreak there was not enough staff to meet the care needs of the residents, the phones were not answered, and not all staff are aware how to retrieve messages to return phone calls.

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.

At the time of the conclusion of this complaint investigation, the issuance of a Civil Penalty was still being determined. However, the Licensee was informed that a Civil Penalty may be assessed based on Health & Safety Code section 1569.49.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview and a copy of report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20210210152517
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: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:
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The Licensee agrees to submit a plan for staff in-service on approved COVID mitigation plan to LPA by POC due date. Proof of training to be submitted to LPA upon completion of training provided.
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Based on observation, interview, and records review the licensee did not provide R1 a safe environment following the recommendations to be homebound with increased COVID monitoring due to health conditions which poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
06/11/2021
Section Cited
CCR
87465(a)(2)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care :...(2) ... In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidence by:

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The Licensee agrees to submit a written declartion to maintain compliance at all times to LPA by POC due date.
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Based on observation, interview, and records review the licensee did not provide R1 transportation to dialysis treatments per physican's orders which poses an immediate health, safety, and personal rights 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: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210210152517
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: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2021
Section Cited
CCR
87411(a)
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Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidence by:
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The Licensee agrees to submit a written declartion to maintain compliance at all times to LPA by POC due date.
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Based on observation, interview, and records review the licensee did not ensure staffing in sufficient numbers to provide R1 services necessary to meet R1's needs which poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
06/11/2021
Section Cited
CCR
87463(a)
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Reappraisals (a)...reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement is not met as evidence by:
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The Licensee agrees to submit a written declartion to maintain compliance at all times to LPA by POC due date.
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Based on observation, interview, and records review the licensee did not ensure R1 was reappraised upon initiation of Home Health services noting R1's high risk to COVID and at the time R1 tested positive for COVID which poses an immediate health, safety, and personal rights 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: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4