502700362-10-28-2020-27-AS-KHOS-BV3KL6-20201105065926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700362
Report Date: 10/28/2020
Date Signed: 10/28/2020 03:18:44 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
08/06/2020 and conducted by Evaluator Tuyet-Suong Teh

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200806091707

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:	10/28/2020
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Heather Payne		TIME COMPLETED:	03:13 PM

ALLEGATION(S):

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Residents diapers not changed in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Suong Teh contacted the facility via telephone to commence a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. The purpose of this visit was to deliver findings for this complaint investigation.

Allegation: Residents diapers not changed in a timely manner
On 08/10/2020, the Department conducted an initial 10-day complaint inspection. LPA contacted the Reporting Party (RP) on 08/10/2020 and 09/29/2020 and left voicemail. On 09/29/2020 LPA conducted telephone interview with staff1, staff 2, staff 3, staff 4 and staff 5 and the former Executive Director. It was learned that the facility has a policy on the Memory Care Unit that all residents shall be checked every 2 hours. Resident records reviews discovered that resident #1 (R1) is placed on incontinent care and need to be check every 2 hours. Interviews revealed that on numerous occasions resident #1 (R1) was left in soak diaper.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2020

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-20200806091707

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: 10/28/2020

NARRATIVE

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Due to the following information, the Department finds the allegation to be SUBSTANTIATED meaning the preponderance of evidence standard has been meet.
A deficiency is being cited on 9099-D, per California Code of Regulation, Title 22
An exit interview was conducted with ED via telephone and a copy of this report will be provided to the facility via email and United States Postal Service. Two copies will be sent to the facility, 1 is to be signed and returned to CCL and the other copy is to be retained by the facility.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
08/06/2020 and conducted by Evaluator Tuyet-Suong Teh

COMPLAINT CONTROL NUMBER: 27-AS-20200806091707

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:	10/28/2020
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Heather Payne		TIME COMPLETED:	03:13 PM

ALLEGATION(S):

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Staff hits residents.

INVESTIGATION FINDINGS:

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Allegation: Staff hits residents
The investigation consisted of interviews with the clients (C-1,2,3,4,5, and 6), staff and other witnesses. File documents were client's case files reviewed. Interviews discovered that allegation is inconsistent.

Based on LPA’s observations and interviews conducted, the information and statements for this complaint and allegations were inconsistent and based on the fact that all 6 clients denied the allegations, the complaint is determined to be UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20200806091707

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: 10/28/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/04/2020 Section Cited CCR 87625(b)(2)	1 2 3 4 5 6 7	87625(b)(2) ) Managed Incontinence: In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidenced by one (1) of one (1) resident reviewed. This posed a potential health and safety risk to resident in care.	1 2 3 4 5 6 7	Licensee agrees to review section 87625, additionally a toileting schedule for all residents whom are incontinent is to be created to ensure they are changed at regular intervals. Staff to document when toileting is completed. Licensee agrees that all staff shall be trained on managed incontinence to ensure that residents are kept clean and dry. Proof of training due to CCL by 11/04/2020.
	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
	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: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Tuyet-Suong Teh	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020

LIC9099 (FAS) - (06/04)

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