502700362-10-27-2020-27-AS-KHOS-BUZNYK-20201103095251

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700362
Report Date: 10/27/2020
Date Signed: 10/27/2020 02:08:52 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
09/08/2020 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200908105945

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:	120	CENSUS: 45	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Heather Payne, Administrator		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Facility has bedbugs
Insufficient staffing

INVESTIGATION FINDINGS:

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On 10/27/2020, Licensing Program Analyst (LPA) T. White contacted the facility to commence a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA White discussed the purpose of the call and the elements of the allegations with Administrator, Heather Payne.

During the course of investigation, LPA conducted interviews with 4 staff members in Assisted Living Unit and attempted interviews with 3 residents in Memory Care Unit. LPA collected documentation and reviewed previous history of complaints in relation to the complaint. Based on incident reports and pest control notes facility has bed bugs. On 09/14/2020 Clark conducted inspection on all community beds and confirmed six beds had bed bug activity. LPA conducted 4 interviews with staff members. 4 of 4 staff members and 3 of 3 residents in Assisted Living stated there are bed bugs in the facility. Clark Pest Control setup for reoccurring inspections once a month. Based on incident report on 09/29/2020, Clark Pest Control has treated bed bugs in the facility.
Report continues on 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

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-20200908105945

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: 10/27/2020

NARRATIVE

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Furthermore, during the course of the investigation, LPA conducted interviews with 4 staff members and 3 residents who resides in Assisted Living. Based on staff interviews, S1 stated on 09/11/2020, the facility has been having staffing problems with the PM shift. S3 stated when AM shift arrives, residents have not been changed and residents are so wet that the bed sheets have to be changed.

Based on interviews with 3 residents, 2 of 3 residents stated the facility is understaffed. On 10/12/2020, R1 stated when a resident presses the call button, there are no staff members to assist the residents. R2 stated she has to wait for staff to help her because of lack of workers. R2 stated usually getting food is a half hour late. R2 stated the lack of staffing results in food being late.

Based on facility history, LPA determined there are multiple instances licensee did not ensure the facility was fully staffed. On 07/30/2020, medications were given 30 minutes late due to the facility being understaffed. On 08/29/2020, S3 reported residents' briefs were not changed due to the facility being understaffed. Facility's end of shifts notes indicated R2 and R5 was found with soaked briefs. The facility has experienced insufficient staffing which causes residents needs not being met.

As a result of this investigation, the Department finds these allegations to be substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency(ies) cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted with Heather Payne. Appeal Rights and a copy of this report was provided to Heather Payne via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200908105945

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: 10/27/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/28/2020 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a): Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Additional staff shall be employed as necessary to perform ... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator has hired an am/pm med-tech. Administrator is currently hiring more care staff. Administrator agrees to email LPA a weekly staff schedule, and provide LPA with hiring updates until 11/30/2020. Administrator agrees to email hiring plan statement to LPA by POC date 10/28/2020.
	8 9 10 11 12 13 14	Based on interviews and documenation, licensee did not comply with the section 87411(a). LPA observed licensee did not ensure residents basic needs were being met, which poses an immediate health and safety risks to residents in care.	8 9 10 11 12 13 14	Administrator agreed to complete a Human resources hiring training course with an outside vendor and submit documentation by 11/06/2020.
Type B 10/30/2020 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a): Maintence and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by	1 2 3 4 5 6 7	Administrator treated the bed bugs in residents bedrooms and submitted proof to CCLD. Administratror agreed to submit Pest control documentation by 10/28/2020.
	8 9 10 11 12 13 14	Based on observation and documentation, licensee did not comply with the section 87303(a). On 09/14/2020 incident reports states the facility has bed bugs which poses a potential health and safety risks to residents in care.	8 9 10 11 12 13 14

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

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