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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 05/29/2021
Date Signed: 05/30/2021 08:15:58 AM

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: 54DATE:
05/29/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Henry EmojevbeTIME COMPLETED:
01:30 PM
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LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check. LPA met with Henry Emojevbe (Med-Tech).

LPA observed staff on duty and the residents eating in the dining hall. LPA toured the facility, during the tour LPA observed a hospice resident (R1) who had just passed away. The hospice agency was called and the room was closed and secured.

Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. The facility appears to have enough food for residents, Staffing for the day shift was at 10 total, this included two med-techs, six direct care staff (three on the assisted living side and three in memory care) and two kitchen staff.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2021
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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