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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700362
Report Date: 05/11/2021
Date Signed: 05/11/2021 03:50:24 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
09/23/2020 and conducted by Evaluator Ruth Wallace
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200923161510
FACILITY NAME:STACIE'S CHALET MODESTOFACILITY NUMBER:
502700362
ADMINISTRATOR:PRADO, ROSIEFACILITY TYPE:
740
ADDRESS:808 MCHENRY AVETELEPHONE:
(209) 524-0808
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:0CENSUS: 0DATE:
05/11/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Responsible Party/James Wong via Telephone Due To Facility Closure on 4/1/21TIME COMPLETED:
02:20 PM
ALLEGATION(S):
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food service lack quality
facility is unkempt- food observed on the ground
INVESTIGATION FINDINGS:
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LIcensing Program Analyst (LPA) Ruth Wallace contacted responsible party to conclude complaint investigation. LPA identified herself and purpose of call to deliver findings for allegations to responsible party.
LPA Ruth Wallace conducted a record review on 5/7/21 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
The facility was cited on 10/27/20 regarding food service lacking quality and quantity. Based on LPA’s interview with previous LPA's, citations, and review of documents provided by previous administrator. There were several dates in the last year that facility did not provide quality or quantity to residents in care. Food orders did not arrive at facility on schedule which created a lack of fresh vegetables and fruits at the time. Licensee did not ensure that the total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents.
The allegation that food service lack quality. The preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. This poses an immediate risk to the health and safety of residents in care.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
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 5
Control Number 27-AS-20200923161510
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
VISIT DATE: 05/11/2021
NARRATIVE
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Continued from 9099 - Page 2

The facility was cited on 10/29/20 regarding facility is unkempt- food observed on the ground in bath, laundry, and kitchen areas of the building. Based on LPA’s interview with previous LPA's, citations, and review of documents provided by previous administrator. Licensee did not ensure that facility shall be clean, safe, sanitary and in good repair at all times. The allegation of facility is unkempt - food observed on the ground. The preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. This poses a potential health, safety, and personal rights risk to residents in care.

Facility closed on 4/1/21. All residents have been relocated to other facilities for purposes of meeting their needs.

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

As a result of this investigation, the Department finds these allegations to be substantiated. The licensee did not provide food service quality or quantity. The licensee did not ensure that the facility was maintaining an adequate food supply to meet the needs of the residents. Licensee did not keep facility clean and food was observed on several floors throughout the facility. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations and appeals rights given to the Responsible party.

An exit interview was conducted with Responsible party via telephone and a copy of this report LIC 9099, 9099-C, 9099-D, Two Civil Penalties 421FC's, and Appeal Rights was provided to the Responsible party via email and an electronic email read receipt confirms receiving these documents. Responsible party will send back 9099, 9099-C, 9099-D, 421FC's via email signed to LPA Wallace.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200923161510
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: 05/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2021
Section Cited
CCR
87555(a)
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87555(a) General Food Service Requirements: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents. This requirement is not met by: Based on evidence: Interview & record review of previous citation on 10/27/20 which is within one year, residents were not receiving daily diet needs. The licensee did not ensure the facility was meeting daily diet needs for residents. This posed an immediate health, safety, & personal rights risk to residents in care.

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Licensee agrees to sign 9099-D for a repeat citation within one year which occurred on 10/27/20 and is being cited again on 5/11/21. The facility closed on 4/1/21 and all residents have been moved to new facility. A repeat civil penalty will be assessed.
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Type B
05/11/2021
Section Cited
CCR
87303(a)(1)
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87303(a)(1) Maintenance and Operation: (a)The facility shall be clean, safe, sanitary and in good repair at all times. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained. This requirement is not met by:
Based on facility inspection on 10/29/20, several floors throughout facility had food on them and debris. The licensee did not ensure the facility kitchen was sanitary. This posed a potential health, safety, & personal rights risk to residents in care.
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Licensee agrees to sign 9099-D for a repeat citation within one year which occurred on 10/29/20 and is being cited again on 5/11/21. The facility closed on 4/1/21 and all residents have been moved to new facility. A repeat civil penalty will be assessed.
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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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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 Ruth Wallace
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200923161510

FACILITY NAME:STACIE'S CHALET MODESTOFACILITY NUMBER:
502700362
ADMINISTRATOR:PRADO, ROSIEFACILITY TYPE:
740
ADDRESS:808 MCHENRY AVETELEPHONE:
(209) 524-0808
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:0CENSUS: 0DATE:
05/11/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Responsible Party/James Wong via Telephone Due To Facility Closure on 4/1/21TIME COMPLETED:
02:20 PM
ALLEGATION(S):
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a non caregiver and un-fingerprinted assisting residents in memory care
laundry is not done on a regular basis
resident rooms are not clean
menu's are not being updated as food changes occur
INVESTIGATION FINDINGS:
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LIcensing Program Analyst (LPA) Ruth Wallace contacted responsible party to conclude complaint investigation. LPA identified herself and purpose of call to deliver findings for allegations to responsible party.
LPA Ruth Wallace conducted a record review on 5/7/21 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 interviewed previous LPA’s, citations, and documents received by previous administrator before closure. The facility closed on 4/1/2021. LPA found no evidence to support that a caregiver was not fingerprint cleared in memory care because the facility closed on 4/1/21. LPA cannot verify one way or another. Therefore; the allegation that a non-caregiver and un-fingerprinted assisting residents in memory care is deemed UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred as reported therefore the allegation was found to be Unsubstantiated.
LPA interviewed previous LPA’s, citations, and documents received by previous administrator before closure. The facility closed on 4/1/2021. LPA found no evidence laundry is not done on a regular basis, but LPA cannot verify one way or another. Therefore; the allegation that laundry is not done on a regular basis is deemed UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred as reported therefore the allegation was found to be Unsubstantiated.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20200923161510
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
VISIT DATE: 05/11/2021
NARRATIVE
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Continued from 9099-A Page 2

LPA interviewed previous LPA’s, citations, and documents received by previous administrator before closure. The facility closed on 4/1/2021. LPA found no evidence resident rooms are not clean, but LPA cannot verify one way or another. Therefore; the allegation that resident rooms are not clean is deemed UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred as reported therefore the allegation was found to be Unsubstantiated.

LPA interviewed previous LPA’s, citations, and documents received by previous administrator before closure. The facility closed on 4/1/2021. Administrator only provided one menu for LPA to review.


Menus are not being updated as food changes occur, LPA cannot verify one way or another. Therefore; the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred as reported therefore the allegation was found to be Unsubstantiated.

As a result of this investigation, the Department finds these allegations to be Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted with Responsible party via telephone and a copy of this report LIC 9099-A, 9099-C and Appeal Rights was provided to the Responsible party via email and an electronic email read receipt confirms receiving these documents. Responsible party will send 9099-A and 9099-C back via email signed to LPA Wallace.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5