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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 09/15/2020
Date Signed: 09/15/2020 04:35:22 PM

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:STACIE'S CHALET STOCKTONFACILITY NUMBER:
392700361
ADMINISTRATOR:PARKER, JADEFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 79DATE:
09/15/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Jade Parker, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Diego Escobar conducted a case management televisit on 9/15/2020. LPA spoke to Jade Parker, Administrator, and explained the purpose of the call.

LPA interviewed Jade with regards to the wound status of Resident 1 (R1). LPA observed R1 had her right shin bandaged. Jade is to send LPA R1's discharge documentation from the hospital visit on 9/3/2020, R1's skin checks and R1's home health notes from September 1, 2020 to present.

No deficiencies were cited during today's visit.

Exit interview was conducted with Jade. Copy of the report sent to Jade via e-mail with a "read receipt" to verify the LIC 9099 was received. Jade is to print out the report, and fax a signed copy to LPA at 916-263-4744.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020
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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