502700362-4-22-2021-27-AS-LKIG-C2JN9X-20210429101636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700362
Report Date: 04/16/2021
Date Signed: 04/22/2021 10:21:48 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
10/06/2020 and conducted by Evaluator Michael Bilger

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201006110652

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:	0	CENSUS: 0	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	N/A Facility Closed 4-1-21		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff are not providing residents with food of good quality

INVESTIGATION FINDINGS:

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LPA Michael Bilger conducted a review of the above allegation on 4/16/21. Facility closed operation on 4-1-21 and residents have since been relocated. As a result, there is no Administrator to meet with to dicuss findings. LPA left message with RP to discuss findings but did not receive a return call. LPA Bilger reviewed previous interviews conducted by LPA T. White on 10/6/2020 which revealed that food was of bad taste, "not edible", and "cold" at times according to the interviewed subject.

Facility has since closed and is no longer in service. As a result, this allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a good perponderance of evidence to provde that the alleged violation occurred.

A copy of this report will be mailed with request for signature.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

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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