502700362-10-27-2020-27-AS-KHOS-BUZNNU-20201103093718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700362
Report Date: 10/27/2020
Date Signed: 10/27/2020 12:10:59 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
08/19/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200819111616

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: 46	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Heather Payne		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Insufficient staff to meet the needs of the residents,
Food service is inadequate.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to commence a complaint investigation via telephone on 10/27/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Heather Payne.

Throughout the course of the investigation, LPA conducted interviews and reviewed facility documents. The investigation allegations are as follows:

1. Insufficient staff to meet the needs of the residents
2. Food service is inadequate.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
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)

Page: 1 of 5

Control Number 27-AS-20200819111616

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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LPA Martinez reviewed resident notes and learned resident 1 (R1) and resident 2 (R2) requested more sausages on 08/16/2020 from care staff 1 (S1). S1 requested additional sausages for R1 and R2, however, S1 was informed by kitchen staff that there was not enough food in the facility. It was reported on facility charting notes that R1 and R2 did not receive additional sausages on 8/16/2020. Resident 3 (R3) reported the facility meal portions are small, and R3 reported going to bed hungry. Resident 4 (R4) reported the meal portions are small.

During an interview with staff 4 (S4), it was learned one of the facility’s weekly food deliveries did not arrive at the facility in September 2020. S4 reported Stacie’s Chalet Stockton delivered food to Stacie’s Chalet Modesto in September. Staff 6 confirmed that the food was delivered by Stacie’s Chalet Stockton staff. However, S4 reports the food delivery was limited. S4 reports there was a shortage of dry food and fruits. LPA Martinez reviewed US Foods invoice. The US Foods reported 15 items not delivered due to being out of stock in the month of September 2020. The food items not delivered were the following:

Potato, SWT Cut CND CKD Yam
Film, Cling 18”x2000
Applesauce Unstn SS Plst Cup
Glove Ntrle Med PF Vlu AMBDX
Glove Ntrle LG PF Vlu AMBDX
Beef, Pty CHPD Chuck & Short
Ice Cream Bar Vnl W/Choc Cro
Pastry Pop Tart Cin FRTD 2
Snack Mix, Trail Nut & Choc SS
Ham Scld .67 W/A VA Style
Beef, Brskt Slcd in BBQ Sauce
Strawberry W/O Stem Clmshl
Blueberry Fresh Ref.
Potato, Tater Nugt PARFR FZN
Pork, Sprb St. Louis 1.7 LB Bl

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
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)

Page: 2 of 5

Control Number 27-AS-20200819111616

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 10/02/2020 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	87555 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:	1 2 3 4 5 6 7	Administrator agrees to: Stock Memory Care Unit refrigerator with snack & food for the PM & Noc shifts. Night and Noc med-techs will be cross trained on kitchen duties and safety procedures
	8 9 10 11 12 13 14	Based on evidence: interview & record review: The licensee did not ensure the facility was meeting R1,R2, R3,R4 daily diet needs. This posed an immediate health, safety, & personal rights risk to residents in care.	8 9 10 11 12 13 14	and given a kitchen key. Kitchen staff will also attend training. Administrator agrees to email training outline agenda and night/noc shift kitchen procedures by POC Date 10/28/2020. Training will be conducted by 11/10/2020
Type A 10/02/2020 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers...to meet resident needs...in facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608...	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.
	8 9 10 11 12 13 14	This requirement is not met by: Based on evidence: interview & record review the licensee did not ensure residents basic needs were being met. This posed an immediate health, safety, & personal rights risk to residents in care.	8 9 10 11 12 13 14	Administrator agrees to email hiring plan statement to LPA by POC date 10/28/2020.

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: Avelina Martinez	TELEPHONE: (916) 263-4809
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)

Page: 3 of 5

Control Number 27-AS-20200819111616

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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In addition, on 10/07/2020 S4 reported the facility has not had apple sauce in over 4 weeks. S4 reported apple sauce is needed and used for soft mechanical diets. S5 reported there were six residents on soft mechanical diets. LPA Martinez reviewed US Foods Invoices from 07/06/2020 thru 10/03/2020. It was reported that the facility ordered applesauce on 7/18/2020 and on 7/25/2020, which the items arrived. The next order of applesauce was 9/27/2020 and 10/03/2020, which did not arrive due to being out of stock.

Staff 5 (S5) reported on the day of the food delivery, facility staff will be informed if a food item is out of stock. In addition, staff 6 (S6) reported facility staff will go to the store to buy the food items that were not delivered. However, on a 10/08/2020 virtual tour of the facility’s kitchen, it was noted there was no applesauce in the kitchen. Moreover, during the tour S5 went to the medication room to check if there was apple sauce in the med room refrigerator. There were (5) applesauce cups in the medication room. The apple sauce in the medication room is used to administer medication. The facility did not ensure to restock/maintain the applesauce supply.

On 10/07/2020, S4 stated, “two weeks ago there was a shortage on fresh fruit.” S4 stated, “there were only 4 watermelons delivered.” S4 reports that food supply is becoming less and less each week on delivery day, which is every Monday. US Foods invoice dated 09/27/2020: reported the facility did not receive the following fruits:

1. Applesauce

2. Strawberries W/O Stems Clmshl

3. Blueberry Fresh REF

Moreover, R7 reported the facility always runs out of bananas by Friday. R7 reported that he was not able to get a banana last week because the facility ran out, however, today on 10/07/2020 R7 was able to get a banana. LPA Martinez reviewed US Foods invoices, and it was learned bananas were not ordered on 08/03/2020 and 9/14/2020. US Food invoices reports the facility on average buys bananas on a weekly basis. The facility purchased bananas on 8/10/2020, 8/17/2020, 8/31/2020, 9/19/2020, 9/27/2020, and 10/03/2020. The facility did not ensure to maintain the facility’s food supply.

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
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)

Page: 4 of 5

Control Number 27-AS-20200819111616

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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LPA Martinez reviewed US Food Service invoices from 07/06/2020 thru 10/03/2020. It was learned the facility did not receive 41 items from US Grove during a three-month period. The inadequacies of the facility’s food service and ordering have resulted in various complaints. As, R1, R2, R3, R4 have voiced their concerns in regards to the food shortage issues. Furthermore, S1 and S4 have also voiced their concern regarding the low food supply in the facility. The licensee did not ensure the facility was adequately maintaining a food supply.

Furthermore, during the investigation, LPA obtained medication administration logs. On 7/30/2020, it was noted on a facility charting note that all medications were given 30 minutes late due to being understaffed. On 07/30/2020, there was only 1 med-tech, therefore, the med-tech could not pass out medications on time. Staff 1 (S1), staff 2 (S2), staff 3 (S3) reported being understaffed and not being able to complete their job duties.

R3 reported that resident 5’s (R5) brief was not changed in over 12 hours. R3 reported that due to lack of staff R5’s brief was not changed. Furthermore, S3 reported on 8/29/2020 residents’ briefs were not changed due to being understaffed. There was one care giver and one med-tech working the night/noc shift for the entire building. A facility’s End of Shift note reports R2 and resident 5 (R5) were found in soaked briefs. On multiple instances, the licensee did not ensure the facility was fully staff. This also, caused residents not to receive basic care services that they require.

As a result of this investigation, the Department finds these allegations to be substantiated. The licensee did not provide basic services to residents due to lack of staff. The licensee did not ensure that the facility was maintaining an adequate food supply to meet the needs of the residents. 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 facility.

An exit interview was conducted with Heather Payne 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: Avelina Martinez	TELEPHONE: (916) 263-4809
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)

Page: 5 of 5