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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/26/2021
Date Signed: 06/26/2021 09:58:52 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:ANURADHA SAINIFACILITY TYPE:
740
ADDRESS:517 E FULTON STTELEPHONE:
(209) 466-2116
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 53DATE:
06/26/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Barbara WilliamsTIME COMPLETED:
10:15 AM
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LPA Avelina Martinez made an unannounced visit on 06/26/2021 to conduct a health and safety check. LPA Martinez met with Barbara Williams and explained the purpose of the visit.

Administrator holds current certificate # 6056677740 and expires on 06/30/2021. The facility is licensed for 114 non-ambulatory residents. There are currently 53 residents who reside at this facility. The facility has a hospice waiver for 10, and there are currently 4 residents receiving hospice services. Additionally, there are 19 residents residing in the memory care unit.


LPA Martinez toured the facility with Barbara Williams at 9:15 AM. LPA Martinez observed staff on duty. No concerns with staffing. The facility is fully staffed for today, and no call outs for today. LPA Martinez observed some residents exercising at the activity area . The temperature in the facility was a comfortable 75 degrees. The air conditioner is fixed and operational. The memory care hall way and dinning room are under construction.

As a result of this visit, a Health and Safety check was conducted, and no deficiencies were observed pursuant to Title 22 Health and Safety regulations.

An exit interview conducted, and a copy of this report was given to Barbara Williams.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2021
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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