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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005503
Report Date: 09/13/2021
Date Signed: 09/14/2021 05:32:45 PM

Document Has Been Signed on 09/14/2021 05:32 PM - It Cannot Be Edited

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:MARYANN PATACSIL'S CARE HOME #2FACILITY NUMBER:
397005503
ADMINISTRATOR:MARYANN PATACSILFACILITY TYPE:
735
ADDRESS:335 PRADO WAYTELEPHONE:
(209) 477-4915
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 6DATE:
09/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Maryann PatacsilTIME COMPLETED:
05:45 PM
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On 09/14/2021 at 2:58pm, Licensing Program Analyst (LPA) Ashley Boothe spoke with Licensee regarding facility risk assessment questions who confirmed no staff or clients have experienced symptoms within the last 10 days. At 3:05pm, LPA arrived unannounced to conduct a case management visit and explained the purpose of today’s visit. LPA was allowed entry into the facility and met with Designated staff (S1) and Licensee arrived shortly after. Census 6.

On 9/13/2021 LPA received a phone call from Licensee for request of Department approval for 3 day eviction of Resident one (R1). During today's inspection LPA conducted interviews and requested records for the departments review. Previous records were requested on 9/13/2021 via email. The Department will review and provide the Licensee a response as outlined in California Code of Regulations Title 22 85068.5 Eviction Procedures.

LPA encountered computer consistency check and stepped away at 4:30pm and returned at 5:00pm to finalize reports and print documents.

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held and a copy of report provided.




SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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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