<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 05/31/2021
Date Signed: 05/31/2021 12:37:48 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:
05/31/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Sue Mishra and Sarah HillsmanTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check. LPA met with Sue Mishra (Med-Tech).

LPA observed staff on duty and the residents eating in the dining hall. Some residents are using the activity area as a cooling station. LPA toured the facility and observed six air conditioners in the facility set at 70 degrees. There is a request that has been submitted to secure three additional units. These units should be delivered on 6/1/2021. The facility room temperatures were measured at 81 degrees in the Assisted Living (AL) side lower floors and 85 degrees in the upper stairs AL side of the buliding. Memory care was also measured at 81 degrees.

Health and Safety check included overall safety of the facility including food supply, physical plant and staffing. The facility has food for residents including dinner this evening, snacks and breakfast for the morning. The Administrator will buy more food items on 6/1/2021. Staffing for the day shift was at 11 total, this included two med-techs, six direct care staff (three on the assisted living side and two in memory care) and three 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: 05/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1