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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/01/2021
Date Signed: 06/01/2021 01:21:23 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: 53DATE:
06/01/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Karon MillsTIME COMPLETED:
02:00 PM
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On 6-1-21pm LPA's Ashley Boothe and Tirzah Hubbard arrived at the facility to conduct a Case Management Health and Safety visit.

LPA's met with Administrator Karon Mills and toured the facility inside and out to ensure the safety of residents in care. Current staff today include 5 caregivers, 3 med tech, 5 dietary staff, 4 administrative staff, 2 house keeping. LPA's measured the temperature of the facility to be at 82 degrees on the first floor, second floor 85 degrees. LPA's observed food supply to meet regulatory requirement of seven day non perishable and perishable foods. LPA's observed residents engaging in daily activities. LPA's observed 10 working portable air conditioners on site to cool the facility due to the main system not in working order.

Based on today’s visit, no deficiencies were cited under Title 22 regulations. A copy of this report and appeal rights were left with Administrator Karon Mills.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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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