502700362-3-19-2021-27-AS-KHOS-BZFPVA-20210325113850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700362
Report Date: 03/02/2021
Date Signed: 03/19/2021 03:36:35 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
02/26/2021 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20210226114500

FACILITY NAME:	STACIE'S CHALET MODESTO		FACILITY NUMBER:	502700362
ADMINISTRATOR:	PAYNE, HEATHER		FACILITY TYPE:	740
ADDRESS:	808 MCHENRY AVE		TELEPHONE:	(209) 524-0808
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	120	CENSUS: 19	DATE:	03/02/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator Ataly Vazquez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident’s room has bed bugs.

INVESTIGATION FINDINGS:

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On 3/19/2021, Licensing Program Analyst (LPA) Jason Lund contacted the facility to complete a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA Lund discussed the purpose of the call and the elements of the allegations with Administrator, Ataly Vazquez. LPA Lund explained to Ataly Vazquez that this was a amended complaint from 3/2/2021. LPA Lund explained in another telephone call on 3/19/21 that this investigation will stay UNSUBSTATIATED. LPA Lund will do a case management visit instead. Current Census 6

During the course of investigation LPA Lund and administrator Heather Payne inspected six rooms and observed no bed bugs in the six rooms. Previous reports from Clark Pest Control confirm the last time the facility had bed bugs was in January of 2021. LPA and Administrator also walked the facility and observed no bed bugs in the rest of the facility.

Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview was conducted with Ataly copy of report provided via email due to COVID 19 precautionary measures, with a read receipt to verify the 809 was received.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

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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