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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700102
Report Date: 05/20/2024
Date Signed: 06/06/2024 02:02:52 PM


Document Has Been Signed on 06/06/2024 02:02 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
05/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:19 PM
MET WITH:Melissa Patacsil & Maryanne Patacsil & Marylin PatacsilTIME COMPLETED:
02:15 PM
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On June 10, 2024 at 1:19 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Michael Bilger arrived at facility unannounced to conduct a case management visit. LPA Martinez met with Melissa Patacsil & Maryanne Patacsil & Marylin Patacsil and explained the purpose of the visit.

The purpose of the visit today is in response to a personal rights concern.

It was learned staff 1 (S1) filmed client 1 (C1) in the bathroom during medical incident. It was also learned the filming took place after C1 showered, and C1 was fully clothed during filming. It learned C1 reported they did not want to be recorded; however, after the incident C1 agreed to be filmed for medical reasons and signed a consent form was completed. As a result, a technical assistance violation was given to the facility due to not having a signed consent form prior to filming the seizure incident.



An exit interview was conducted, and a copy of this 809 report, Technical Violation page were provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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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