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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700362
Report Date: 04/16/2021
Date Signed: 04/22/2021 10:19:36 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 MODESTOFACILITY NUMBER:
502700362
ADMINISTRATOR:PAYNE, HEATHERFACILITY TYPE:
740
ADDRESS:808 MCHENRY AVETELEPHONE:
(209) 524-0808
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:0CENSUS: DATE:
04/16/2021
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:N/A - Facility ClosedTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff not responding to residents call button

Inadequate staffing to meet residents' needs
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 10/6/2020 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 sustantianted allegation from 10/28/2020 regarding residents needs not being met. In addition, LPA reviewed a substantatied allegation from 10/27/2020 regarding insufficient staffing to meet resident's needs.

Due to previous allegations including a previously substaintiated allegation 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 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)
Page: 1 of 2
Control Number 27-AS-20201006110652
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)
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87468.1 Personal Rights of Residents in all facilities (a)(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on previous interviews and record reviews, licensee did not ensure a timely response to resident call buttons. This poses an immediate health and safety risk to
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Facility is closed as of 4/1/21 and all residents have been reloacted to other facilities suitable to meet their needs.
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Resident's in care.
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Type A
04/19/2021
Section Cited
CCR
87411(a)
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87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The requirement is not met as evidenced by: Based on previous interviews and record reviews licensee did not ensure basic needs were being met by staff. This poses an
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Facility is closed as of 4/1/21 and all residents have been reloacted to other facilities suitable to meet their needs.
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immediate health and safety 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: Michael BilgerTELEPHONE: 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)
Page: 2 of 2