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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/09/2021
Date Signed: 06/09/2021 10:54:30 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: 53DATE:
06/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Karon Mills, AdministratorTIME COMPLETED:
10:54 AM
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Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a Health and Safety inspection on 6/9/21 at 9:35am. LPA met with Administrator, Karon Mills and stated the purpose of today’s visit. LPA was allowed entry and screened at the front door 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 and compliance with Title 22 regulations. The temperature inside the facility was measured at 74*F in common dining room, 76*F in Assisted Living (AL) first floor, 73*F in AL second floor, and 76*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 throughout the facility.

LPA observed food supplies of 7 days of nonperishable foods and 2 days of perishable foods on site. Menu for 6-9-21 included Egg Casserole, Yogurt, Fruit Cocktail, Juice, Grain Toast, Beverage for breakfast; Lunch: Green salad, chicken skillet, parsley rice, peas, bread roll, beverage, cococut cake; Dinner: Sub sandwhich, cantaloupe, crunchy kale salad, ice cream. An estimated $3000 of food was bought on 6-8-21 from an outside retailer. Today's staffing included 6 caregivers in AL and 5 caregivers in MC to cover AM, PM and night shifts, 5 med techs in AL to cover AM, PM, and night shifts; 3 Med Techs in MC to cover AM, PM, and night shifts, 5 dietary staff and 2 housekeepers.

As a result of today’s 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 along with appeals rights.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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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