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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/25/2021
Date Signed: 06/25/2021 01:57:31 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:
06/25/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Anu Saini, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a Health and Safety inspection on 6/25/21 at 10:09am. LPA met with Administrator, Anu 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.

The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. Repairs are currently underway which includes phone system and call system. Air conditioning unit is functioning properly. Other repairs have been completed which include entry way ceiling area. The temperature inside the facility was measured at 72*F throughout.

LPA observed food supplies of 7 days of nonperishable foods and 2 days of perishable foods on site. Menu for 6-25-21 included cereal, eggs, hash, fruit, toast and beverage for breakfast; Lunch: Salad, Tilapia, Rice, Bread, and beverage with Strawberry shortcake for dessert; Dinner: Pizza, fruit, salad, beverage and dessert. Administrator stated cisco is currently providing food. Today's staffing includes 9 caregivers, 6 med techs, 2 dietary staff, 1 driver, 1 housekeeping.

As a result of today’s visit, no deficiencies were observed pursuant to Title 22 regulations, Health and Safety Codes. Exit interview conducted with Anu Saini, Administrator and a copy of report was left with Anu.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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