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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/29/2021
Date Signed: 06/29/2021 02:09:56 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) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 54DATE:
06/29/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Anuradha SainiTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a Health and Safety inspection on 6/29/21 at 12:57pm. LPA met with 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. There are 35 residents in AL and 19 residents in MC

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 throughout facility, within the required range of 68*F and 85 *F. LPA observed air conditioning unit to be functioning properly. Administrator stated that a technician will be out on 6-30-21 to address memory care door repair and delayed egress system. Administrator stated elevator vendor will be scheduled to come to facility for an inspection to address repairs requested by Department of Industrial Relations (DIR). Administrator stated outstanding invoice will be paid to DIR as part of the process for final permit issuance. LPA did not observe toxins and other chemicals accessible to residents in care. All door stops have been removed from resident doors at this time.

LPA observed food supplies of 7 days of nonperishable foods and 2 days of perishable foods on site. Administrator stated food supply continues to be serviced by outside company. Today's staffing included 1 door screener, 6 caregivers in Assisted Living, 6 Caregivers in Memory Care. Of these caregivers, there are 3 Med Techs on duty for today. 3 dietary staff are on duty.

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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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