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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700101
Report Date: 02/06/2023
Date Signed: 02/06/2023 01:06:47 PM

Document Has Been Signed on 02/06/2023 01:06 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: 4DATE:
02/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Melissa PatacsilTIME COMPLETED:
01:10 PM
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On 2/6/23 at approximately 12:30pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a health and safety check related to a resident that was relocated as a result of the winter storm 22/23. LPA Jensen met with Licensee Melissa Patacsil and explained the purpose of today's visit.

LPA Jensen toured the facility including the grounds, kitchen, and bathroom. The facility was observed to have a 2 day supply of perishable food and 7 day supply. The medication was observed to be locked and inaccessible to residents in care. The Medication Administration Record was adequately documented. Resident 1 (R1) was observed to be content. LPA Jensen observed all needed medical equipment was available. The wheelchair for resident 1 was measured at approximately 23 inches and the bathroom doorway was measured at 25 inches. There is a nurse on staff that comes approximately 2-3 per week and is available to come more often if needed.

No deficiencies were noted. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2023
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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