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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/02/2021
Date Signed: 06/02/2021 10:40:47 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:
06/02/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karon MillsTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Anthony Tuck made an unannounced visit on 06/02/2021 to conduct a health and safety check. LPA met with Executive Director Karon Mills

LPA observed staff on duty and the residents in the activity hall watching television.
LPA observed residents walking around talking with each other. LPA toured the facility and observed 10 air conditioners in the facility set at 70 degrees. The thermostat in the dining hall and activity room was measured at 71 degrees Fahrenheit. The facility room temperatures were measured at 79 degrees Fahrenheit in the Assisted Living (AL) side lower floors and 82 degrees Fahrenheit in the upper stairs AL side of the building. Memory care was also measured at 78 degrees. LPA toured assisted living floor and memory care floor and observed resident rooms to be clean. LPA briefly spoke with staff on duty and residents who were walking around and in the activity room. Residents were happy and talked about activities they enjoy and the meals that are served from the kitchen.

Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. The facility had sufficient food for residents and does grocery shopping twice per week. LPA learned that the new owner is going to contract with Cisco foods. Staffing for the day shift was at 16 total, this included three med-techs, five direct care staff (two on the assisted living side and three in memory care) and five kitchen staff.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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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