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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 09/03/2020
Date Signed: 09/03/2020 10:04:34 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:PRADO, ROSIEFACILITY TYPE:
740
ADDRESS:808 MCHENRY AVETELEPHONE:
(209) 524-0808
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:120CENSUS: 53DATE:
09/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Heather Payne, StaffTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analysts (LPA) Diego Escobar and Ashley Boothe conducted an unannounced Case Management visit on 9/3/2020 at 9:30 AM to conduct a health and safety check visit. During the visit, LPA met with, Heather Payne, Staff , and stated the purpose of the visit.

LPAs toured the facility kitchen with Heather. LPAs observed at least one week of non-perishable foods and two days of perishable foods. LPAs obtained copies of staff schedule for the month of September and an itemized list of foods deliver to the facility every week. LPA Escobar spoke to Eleina Ridolfi, acting administrator, on 9/3/2020 and it was confirmed that the licensee did not have a certified administrator at the facility from 8/15/2020 to at least 8/26/2020.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Heather Payne and Eleina Ridolfi.

Copy of this report was provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MODESTO
FACILITY NUMBER: 502700362
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/03/2020
Section Cited

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(a) All facilities shall have a qualified and currently certified administrator...

This requirement has not been met as evidenced by:
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Based on interview and record review, the licensee did not comply with the regulation cited above by not having a qualified administrator at the facility from 8/15/2020 to at least 8/26/2020 which poses a potential personal rights and health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2020
LIC809 (FAS) - (06/04)
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