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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/16/2021
Date Signed: 06/16/2021 03:59:08 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: DATE:
06/16/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Barbara WilliamsTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Health and Safety inspection on 6/16/2021 at 3:15pm. Prior to today's visit LPA called the facility for COVID screening and was unable to leave a voicemail message at 8:12am, voicemail box full. LPA screened COVID upon entry. LPA met with Designated Staff Barbara Williams 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 on Hospice.

LPA interacted with a random number of residents during this visit. The physical plant was toured inside to ensure the safety of the residents. The temperature inside the facility was measured in various locations between 84*F and 86*F within the required range of 68*F and 85 *F and in areas of extreme heat the maximum shall be 30*F less than the outside temperature. LPA observed air conditioning units in working order pumping cool air into the facility and fans. LPA observed ample food supplies of staple nonperishable foods and fresh perishable foods recently purchased within regulatory range of 7 day non perishable and 2 day perishable food supplies to be maintained on site at all times. LPA observed food preparation of dinner and lunch to include a variety of nutritious foods properly stored and unexpired. Foods now ordered and delivered weekly on Thursday's through Sysco. LPA observed residents rooms to include the required furniture and lighting. LPA observed knives and toxins secured inaccessible to residents. LPA observed residents engaged in activities. LPA observed maintenance crew on site conducting repairs to the facility. Today's staffing includes 2 caregivers, 2 med tech/caregiver, 2 dietary staff, 2 housekeeping, and 5 administrative staff/driver on site during the visit. Barbara stated one call off med tech scheduled from 2:30pm-11pm and she was covering and staying late.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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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