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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 10/01/2020
Date Signed: 10/01/2020 05:26:00 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 MODESTOFACILITY NUMBER:
502700362
ADMINISTRATOR:PAYNE, HEATHERFACILITY TYPE:
740
ADDRESS:808 MCHENRY AVETELEPHONE:
(209) 524-0808
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:120CENSUS: DATE:
10/01/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Patricia WangTIME COMPLETED:
05:25 PM
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On 10/01/2020 at 4:00pm, CCLD Sacramento South conducted a conference call with the Licensee. Present for the call was Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Czarinna Camilon-Lee, Licensing Program Manager (LPM) Liza King,Licensing Program Analyst (LPA) Treana White, Licensing Program Analyst (LPA) Diego Escobar, Ombudsman (OMB) Melissa Flaherty (Stanislaus) and Jill Hernandez (San Joaquin), Assisted Living Waver program (ALWP) Program Michael Luu, Andrew Lausmann and Jennifer Ward and COO, Grbeshi Hatixhe and Licensee, Patricia Wang to discuss recent concerns at the facility. RM discussed concerns regarding solvency and unpaid bills. Licensee was advised that she has unpaid vendor bills to include staffing agencies and PG&E. Licensee stated she will pay PG&E immediately and submit copy to CCLD. Licensee ensured the facilities bills will be paid, including staffing agency and provide copies to the CCLD. RM advised that a Mitigation Plan is needed for all facilities. Mitigation plan will be submitted within seven days per PIN 20-23 ASC and the PIN will be provided to her. RM informed Licensee to let CCLD know once there is a potential buyer for Modesto and for Stockton. It was learned the facilities have not been sold but they are exploring options. They were advised to work with their respective LPA’s to ensure regulatory compliance is being followed. The Licensee stated she entrusted her operation to A&A and were dropped without notice and they were responsible for paying bills. The Licensee was advised there is an outstanding complaint regarding solvency and the auditor requested documents to be submitted by October 9, 2020 to the auditor. The Licensee was advised that she needs to have the residents separated by COVID status immediately and the staff should be wearing PPE and face coverings (discussions held regarding resources). Discussions held regarding overall physical plant concerns at Stockton from todays visit (with citations) and advised to communicate with their Administrators as they are trying to contact her. The Licensee was reminded of her responsibility of the overall operation.
The Ombudsman and the ALWP advised they are available for support should they need. The most recent PINS were emailed to the Licensee. Licensee was advised to contact the RO if she has questions or concerns. Exit interviewed conducted and copy of report submitted via email. Licensee is to sign and send back to LPA.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020
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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