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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700102
Report Date: 11/08/2022
Date Signed: 11/08/2022 11:02:02 AM

Document Has Been Signed on 11/08/2022 11:02 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 1FACILITY NUMBER:
392700102
ADMINISTRATOR:PATACSIL, MELISSAFACILITY TYPE:
735
ADDRESS:9082 CHIANTI CIRCLETELEPHONE:
(209) 477-4773
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 4DATE:
11/08/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Melissa KimTIME COMPLETED:
11:00 AM
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On 11-8-22 at 10:01am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a collateral visit related to complaint #27-AS-20221011082218. LPA met with Administrator Melissa Kim and explained the purpose of the visit. During today's visit, LPA conducted an interview with Staff1 (S1) as part of the investigation process. Interview was conducted privately. All residents were attending day program during this visit.

No deficiencies cited today. An exit interview was conducted with Melissa Kim and a copy of this report was left with Melissa.




SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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