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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/15/2021
Date Signed: 06/15/2021 12:21:31 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:ANURADHA SAINIFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 54DATE:
06/15/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Anuradha Saini, AdministratorTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Bruce Jacobs arrived unannounced to conduct a Health and Safety inspection on this date LPA met with Facility Administrator, Anuradha Saini and stated the purpose of today’s visit. LPA was allowed entry into the facility with current census of 54 residents of which 4 are hospice and 18 in memory care.

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 75*F in common dining room and 78*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. Lunch was being served and included pasta, salad and garlic bread. Administrator stated facility will began ordering food through Cisco, started on Monday 6/7/21 and the first delivery is scheduled for this afternoon. An ordering schedule is to be determined following a meeting with Cisco on 6/7/21. Today's staffing included 7 caregivers including two med techs.

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: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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