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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700101
Report Date: 08/31/2021
Date Signed: 08/31/2021 04:53:14 PM

Document Has Been Signed on 08/31/2021 04:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:MELISSA PATACSIL'S CARE HOME 2FACILITY NUMBER:
392700101
ADMINISTRATOR:PATACSIL, MELISSAFACILITY TYPE:
735
ADDRESS:8401 CAYUGA DRIVETELEPHONE:
(209) 477-4860
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 3DATE:
08/31/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Miken Gambol, lead caregiverTIME COMPLETED:
05:02 PM
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On 8-31-21 at 2:01pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management on an incident that occurred on 8-18-21. LPA met with lead caregiver Miken Gambol and explained the purpose of the visit. Administrator Marilyn Patacsil was notified by LPA by phone who gave permission for lead caregiver to sign in her absence. LPA conducted health and safety check to ensure Title 22 compliance. LPA was checked for temperature and COVID screening upon entry. There are currently 3 residents residing at facility. Two staff members were present. No sharp object or toxins accessible to residents in care. Outside area was secure and free of obstructions. LPA requested the following documents: Physician report for resident1 (R1), caregiver progress notes for R1, emergency contact form for R1, Individualized Program Plan (IPP) for R1, and facility emergency protocol procedures.

LPA conducted interviews with Staff2 (S2), and S3 at facility. LPA conducted interview with Staff1 (S1) by phone. LPA also reviewed facility file documentation collected during today's visit. LPA additionally reviewed incident report and death report for R1.

Additional time is necessary to complete this case management. LPA will contact Licensee for completion at a later date. No defieciencies were observed during today's visit. An exit interview and a copy of this report was left with lead caregiver Miken Gambol.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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