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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700102
Report Date: 04/25/2022
Date Signed: 04/25/2022 04:58:16 PM

Document Has Been Signed on 04/25/2022 04:58 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 1FACILITY NUMBER:
392700102
ADMINISTRATOR:PATACSIL, MELISSAFACILITY TYPE:
735
ADDRESS:9082 CHIANTI CIRCLETELEPHONE:
(209) 477-4773
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 4DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Melissa Patascil, Staff MemberTIME COMPLETED:
02:05 PM
NARRATIVE
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On 04/25/2022 at 9:15 am, Licensing Program Analysts (LPAs) T. White and R. Campbell arrived unannounced to conduct a required 1-year Annual inspection. LPAs met with and explained to Staff Member, Melissa Patascil the purpose of today’s inspection. Staff confirmed no staff or clients have experienced symptoms within the last 10 days. 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. LPA 's observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature measured at 119 degrees Fahrenheit. All toilets, hand washing, and bathing areas 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 alarms 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 03/05/22. LPAs reviewed 3 client files and 3 staff record files.

LPAs observed unlocked chemicals (two gallons of alcohol and two cans of clorox spray) located in the hallway closet and laundry cabinets accessible to clients.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Staff. A copy of the report and appeal rights 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)
Page: 1 of 2
Document Has Been Signed on 04/25/2022 04:58 PM - It Cannot Be Edited


Created By: Treana White On 04/25/2022 at 01:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MELISSA PATACSIL'S CARE HOME 1
FACILITY NUMBER: 392700102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in 80087(g) out of CCR. LPAS observed chemicals accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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LPA's observed Staff removed chemicals and locked ithem away. Staff purchased a lock for the hallway cabinet.

Deficiency cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
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