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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/04/2021
Date Signed: 06/04/2021 12:03:24 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:
06/04/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Karon Mills, Executive DirectorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Treana White arrived unannounced to conduct a Health and Safety inspection on 06/04/21 at 11:10am. LPA met with Administrator, Karon Mills and stated the purpose of today’s visit. LPA was allowed entry into the facility with current census of 53 residents of which 4 are hospice.

The physical plant was toured inside and outside to ensure the safety of the residents. The temperature inside the facility was measured at 77 *F in common dinning room, 81 degree F. in Assisted Living (AL) first floor, 83 degree F in AL second floor, and 80 degree F in Memory Care (MC) within the required range of 68*F and 85 *F. LPA observed 10 air conditioning units in working order pumping cool air into the facility and fans.

LPA observed food supplies of staple nonperishable foods and fresh perishable foods on site. Administrator stated facility will begin ordering online through Cisco, starting Monday. Today's staffing included 1 door screener, 4 caregivers, 3 med techs, 5 dietary staff, and 1 administrative staff/ driver on site during the visit.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted with Administrator and a copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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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