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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/22/2021
Date Signed: 06/22/2021 12:09:27 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:
06/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Sunny SainiTIME COMPLETED:
12:15 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 Sunny and Anuradha Saini.

LPA observed staff on duty and the residents eating in the dining hall. Some residents in the activity area watching television. LPA was able to review a working schedule for the week on the Administrator's laptop. The schedules will be electronically accessible to all staff.

The temperature in the facility was a comfortable 74 degrees in the Assisted Living (AL) side lower. There was constructions happening in the main entrance. As a reminder the facility must during construction ensure that during all phases of alteration to the facility, maintain the facility in compliance with Title 22 regulations. The licensee must protect the clients in care from any health and safety hazards during and/or resulting from construction. For example, if the construction process presents any danger, the licensee is responsible to ensure the clients have no access to that area. LPA observed safety signs posted.

Health and Safety check today included overall safety of the facility including food supply, physical plant and staffing. The facility has food for residents including breakfast this morning, snacks and dinner for this evening. Staffing for the day shift was at adequate. 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: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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