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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700361
Report Date: 06/30/2021
Date Signed: 07/01/2021 07:40:34 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) 910-5910
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:114CENSUS: 54DATE:
06/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Anuradha Saini, AdministratorTIME COMPLETED:
03:15 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
On 6/30/21 at 2:05 PM, Licensing Program Analyst (LPA) Bruce Jacobs conducted an unannounced pre-licensing visit. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA were accompanied by Administrator and toured the facility inside and out on 6/28/21 and on this visit the purpose of the visit was to ensure the delayed egress system in the memory care was operations. The system was serviced on 6/29/21 and was tested on this date and was fully functional. There were no other deficiencies identified on this date. LPA Jacobs conducted the Component III Pre-Licensing instruction on 6/28/21.

On 6/28/21, all area were inspected and the information is summarized: .Temperature in building was 76*F throughout. Kitchen contained adequate food supply. LPAs checked itemized list of repairs. Roof in lobby has been replaced, RV and non-working bus have been removed from the property, battery has been replaced in the ansul system; Administrator stated fire inspection is scheduled for today 6-28-21 to verify working ansul system. A request for permit was noted in the elevator. Administrator will follow up with elevator service company to obtain permit. Paper towel holders were noted in resident rooms. Light bulbs and ballasts were in working order. Memory care cabinets have been repaired. Window screens have been repaired. Memory care patio fence has been replaced. Memory care patio wires, pipes, and drip lines have been repaired. Telephone system has been upgraded and call forwarding is now in place. Resident rights posting are in place. Door stoppers have been removed from resident doors.

No deficiencies were identified on this visit and this report to be sent to the Application Unit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021
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