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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700101
Report Date: 04/28/2022
Date Signed: 04/29/2022 08:48:43 AM

Document Has Been Signed on 04/29/2022 08:48 AM - 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:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Melissa Patascil, Care StaffTIME COMPLETED:
03:55 PM
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On 04/28/2022 at 12:50 pm, Licensing Program Analyst (LPAs) T. White and R. Campbell arrived unannounced to conduct a required 1-year Annual inspection. LPAs met with Care Staff, Melissa Patascil and explained the purpose of today’s inspection. LPAs were allowed entry into the facility that is licensed to serve a total capacity of 6 non-ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 72 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature measured at 105.6 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishable and 2-day perishables foods.

LPAs observed smoke detectors and carbon monoxide alarm in operating condition during inspection. Fire extinguisher was last serviced on March 09, 2022. Mitigation plan observed to be complete. First aid kit was observed to be complete. Fire drill was last conducted on 04/07/2022. LPA's reviewed three client files and three staff files and a sample of client medications.

No deficiencies cited during inspection.

Exit interview conducted with care staff and a copy of report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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