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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 05/27/2021
Date Signed: 05/27/2021 03:05:06 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:
05/27/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Karon Mulls, AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst Bruce Jacobs conducted a facility visit to conduct a Health and Safety check. Food supplies were inspected and determined to be adequate. Meal preparation was in progress and the facility was following the posted menu. Facility had 3 caregivers and 3 med techs on the schedule for the 54 residents. Facility also has 2 dietary staff and 2 housekeeping who are crossed trained as caregivers. LPA inspected and monitor the air-conditioning units and facility temperature. The facility's main air conditioning unit is not working and has not been working for approximately the last 30 days. The facility has bought in 6 large portable air conditioning units and is working with the property owner for a long term solution. The facility was toured and the temperature through out the care home was measured at 78 degrees F.

No deficiencies were identified on this visit
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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