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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 05/11/2021
Date Signed: 05/11/2021 04:40:07 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:KARON MILLSFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: DATE:
05/11/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:James WongTIME COMPLETED:
04:30 PM
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On 05/11/21 Licensing Program Manager (LPM) Liza King, Krystall Moore, Regional Manager (RM), Ashley Boothe, Licensing Program Analyst (LPA) and Associate Government Program Analyst (LPA) Shannon Betker conducted an announced office visit via Teams at 4:15pm with current licensee appointee James Wong. The purpose of today’s call is to discuss the need for a lease back agreement related to the sale of the property and the pending application for a CHOW. The sale of the property is proposed to close as early as May 14th, however the repairs necessary for prelicensure will not be completed until after the sale of the property.

Mr. Wong stated that he has spoken to both the Broker and the applicant and all parties are aware of the need for the lease back agreement. Mr. Wong stated that the agreement will be tentatively in place by May 14, 2021.

LPA stated that all required documents have been submitted to CAB, pending documents needed is a Health Screening for the new Administrator and page one of the LIC200 has Jade Parker as the Admin and will need to be updated.

An exit interview was conducted with Mr. Wong. A copy of this report was provided to via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Mr. Wong is to print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov

SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
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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