392700361-6-7-2021-27-AS-LKIG-C49LJB-20210623084739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700361
Report Date: 06/07/2021
Date Signed: 06/07/2021 01:51:56 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
06/03/2021 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20210603141128

FACILITY NAME:	STACIE'S CHALET STOCKTON		FACILITY NUMBER:	392700361
ADMINISTRATOR:	KARON MILLS		FACILITY TYPE:	740
ADDRESS:	517 E FULTON ST		TELEPHONE:	(209) 466-2116
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95204
CAPACITY:	114	CENSUS: 53	DATE:	06/07/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Karon Mills, Administrator		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility did not provide authorized representative a refund after resident passed away

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced complaint visit to the facility today to open a complaint investigation for the allegation(s) listed above. LPA met with Karon Mills, Administrator, and advised the purpose of LPA's visit. Complaint alleges that a refund was not issued upon the death of Resident 1( R1) to R1's responsible person. LPA reviewed facility's admission agreement. According to the clause "refunds" responsible persons are entitled to a prorated refund after the death of a resident after all personal belongings are removed. LPA interviewed Administrator who stated that between 4/9/21 and 4/30/21 that R1s responsible person stated she did not want any personal belongings from the room. Administrator stated on 4/30/21 she made a request via email to facility's Certified Public Accountant (CPA) to issue a refund check to R1s responsible person. Administrator stated on 5/12/21 that she followed up with CPA and was told that he needed the amount to issue a check. Administrator stated on 6/3/21 that she received an email request from R1s responsible person and forwarded email to CPA with request to process refund check. On 6/7/21, Administrator stated she sent an email to CPA asking CPA to overnight a refund check to R1s responsible person. (Cont. on 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

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 3

Control Number 27-AS-20210603141128

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: 06/07/2021

NARRATIVE

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Based on Administrator interview and review of refund policy as stated in the Admission agreement, there is evidence that R1s responsible person was not issued a refund since the death of R1 on 4/9/21, therefore this allegation is SUBSTANTIATED.

Deficiencies were cited today under Title 22, Division 6, Health and Safety Codes, Chapter 3.2, Article 6.

A copy of this report was left with Administrator along with appeal rights.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210603141128

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: 06/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/11/2021 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual... individuals contractually responsible for the fees...within 15 days after the personal property is removed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will coordinate with facility's CPA to immediately issue a refund check to R1s responsible person and submit photo proof of refund to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, Licensee did not ensure a refund to R1s responsible party within 15 days after the death of R1 and R1s responsible person's statement of not wanting any personal belonging from the room. This poses a potential health, safety, and resident rights risks to residents in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

LIC9099 (FAS) - (06/04)

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