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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700102
Report Date: 06/20/2023
Date Signed: 06/26/2023 08:16:32 AM

Document Has Been Signed on 06/26/2023 08:16 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
SACRAMENTO AC/SC, 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:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Marilyn Patacsil, AdministratorTIME COMPLETED:
09:53 AM
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LPA Renee Campbell arrived to facility and met with Marilyn Patacsil, Administrator and her daughter, Maryann Masaya, LPA Campbell stated the purpose of the facility. Maryann opened doors and cabinets for inspection. Knives were shown stored under the sink. Toxins and cleaning agents were under lock and key as well. Enough perishable foods for two days were in the refrigerator and there were enough foods items in the for more than seven days. Staff, Prince Andre arrived to open the staff room so LPA Campbell could inspect it. All staff present were cleared and affiliated with the facility. Resident bedrooms were observed with required bed, night table, chair as well as closet.
6041673735
LPA Campbell measured the temperature for the resident's bathroom. Hot water was measured at 115 degrees Fahrenheit. The facility temperature was kept at 71 degrees Fahrenheit. There is an interconnected smoke and carbon monoxide alarm that was tested and was functional. A fire extinguisher had a tag with a date of inspection of 03/09/2023. LPA Campbell requested the Fire Drill log and found that the last drill was done on 05/13/23.

At about 10:15 am, Administrator Marilyn Patacsil and Staff Maryann Masaya left the facility to attend a meeting. Staff Prince Andre and Staff Ammie Adan remained and were authorized to sign facility reports resulting from today's visit. LPA then inspected the backyard and observed a fire exit with latch. The back lawn was well maintained with manicured grass, seating and tables without debris and unobstructed walkways.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MELISSA PATACSIL'S CARE HOME 1
FACILITY NUMBER: 392700102
VISIT DATE: 06/20/2023
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Towards the end of the inspection, Administrator Melissa Kim (#6041673735) arrived to complete and sign for the inspection.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/27/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies issued during the visit.

Exit interview conducted with a copy of this report was provided.
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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