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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700101
Report Date: 04/25/2022
Date Signed: 04/25/2022 03:41:24 PM

Document Has Been Signed on 04/25/2022 03:41 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:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Melissa Patascil, Staff MemberTIME COMPLETED:
03:55 PM
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On 04/25/2022, Licensing Program Analysts (LPAs),T. White and R. Campbell conducted an unannounced case management visit to follow up on an incident, which occurred on 03/31/2022. LPAs met with Staff Member, Melissa Patascil and explained the purpose of the visit.

LPAs White and Campbell reviewed the incident report submitted to CCLD on 04/02/2022. Based on the incident report, During Resident#1 (R1) brief change, direct care staff observed an open area on buttocks. Per facility RN, the open area was very small. The staff was advised to monitor area more often and keep area clean and dry.

Based on Staff #1 (S1) interview, facility Registered Nurse (RN) determined open area is unstageable. RN advised staff to monitor and observe R1's wound throughout the day. Staff #2 (S2) stated staff rotate R1 often and apply medication to wound daily. LPAs observed Licensee is following CCLD guidelines.

No deficiencies cited during visit.

Exit interview conducted with Staff Member and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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