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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 05/28/2021
Date Signed: 05/28/2021 10:53:10 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:
05/28/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Sara HillsmanTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Health and Safety inspection on 5/28/2021 at 9:15am. LPA met with Designated facility staff Sarah Hillsman and stated the purpose of today’s visit. LPA was allowed entry into the facility with current census of 54 residents of which 3 are hospice.

LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. The temperature inside the facility was measured at 74 *F in common dinning room, 76 *F in AL first floor and 84 *F in the kitchen which is within the required range of 68*F and 85 *F. LPA observed 6 air conditioning units in working order pumping cool air into the facility, the main air conditioning unit is not in working order. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. Nutritious meals with a variety of foods were scheduled on weekly menu and LPA observed kitchen staff preparing foods following food safety protocols matching today's menu. Today's staffing included 3 caregivers, 3 med techs, 2 dietary staff, 2 houskeepers, 1 bus driver and 1 administrative staff on site during the visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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