502700362-4-22-2021-27-AS-LKIG-C2JN6C-20210429101054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700362
Report Date: 04/16/2021
Date Signed: 04/22/2021 10:28:10 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
09/23/2020 and conducted by Evaluator Michael Bilger

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200923112226

FACILITY NAME:	STACIE'S CHALET MODESTO		FACILITY NUMBER:	502700362
ADMINISTRATOR:	PRADO, ROSIE		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:	02:54 PM
MET WITH:	N/A Facility Closed 4/1/21		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Resident's diapering needs are not being met

Resident's hygiene needs are not being met

INVESTIGATION FINDINGS:

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LPA Michael Bilger conducted a record review on 4/16/21 to deliver findings of the above allegations.There is no administrator and LPA is unable to conduct an in-person investigation due to facility closure on 4/1/21. LPA reviewed previous interview of reporting party (RP) conducted by LPA T. White on 9/24/20 to receive details of RP's statement. LPA also reviewed previously reported allegation reports of similar nature recorded on 9/23/2020. These reports contained complaints which address lack of staffing and response to resident needs. Additionally LPA reviewed a previously substantiated allegation from 10/28/2020 regarding residents needs not being met. In addition, LPA reviewed a substantiated allegation from 10/27/2020 regarding insufficient staffing to meet resident's needs. LPA also spoke with RP today 4/16/21 at 2:47pm and RP confirmed the allegations from 9/24/2020.

Due to previous allegations including previously substantiated allegations within close proximity to the allegations noted above, there is a preponderance of evidence to conclude that the allegations noted above are SUBSTANTIATED.

Substantiated

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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Control Number 27-AS-20200923112226

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 MODESTO	FACILITY NUMBER: 502700362
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/19/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 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 was not met as evidenced by: Based on record reviews and interviews	1 2 3 4 5 6 7	Facility closed on 4/1/21. All residents have been relocated to other facilities for purposes of meeting their needs.
	8 9 10 11 12 13 14	Licensee did not ensure diapering and hygiene needs were met.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

LIC9099 (FAS) - (06/04)

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