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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 02/24/2021
Date Signed: 02/24/2021 03:49:07 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:
02/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Heather PayneTIME COMPLETED:
12:00 PM
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An Office meeting was held on 2/24/2021 via WebEx to discuss the closing of the facility. Present at the meeting was Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Stephenie Doub, LPA Jason Lund, Auditor (DSS) Diana Chapman and facility representatives Licensee James Wong, and Administrator Heather Payne. Current Census is 19.
Issues discussed during the meeting were:
The facility by the end of business day will provide a copy of roster of residents that have moved and those that still reside at the facility along with documentation of reimbursements provided to residents who have left the facility.

The facility provided a closer plan to CCL and was informed to follow the plan per Reginal Manager (RM) Krystall Moore.

The facility will keep LPA Jason Lund appraised of the status of repairs needed to the delayed egress door.

The facility will send a daily roster when a resident moves out of the facility and the reimbursement to the resident or residents when they leave the facility.

The facility will keep auditor Diana Chapman appraised of the outstanding food bill to make sure the facility is still receiving food orders to provide meals to residents.

The facility will do re-appraisals for all residents to assess relocation needs and determine which residents may be able to remain at the facility under the new license.

The facility will conduct a virtual town hall meeting with ombudsman, residents and residents POA’s via a network, to make sure the residents are properly informed of their rights about moving out of the facility. The facility will provide LPA Jason Lund the date of the town hall meeting.
An exit interview was conducted with James Wong Licensee and Administrator Heather Payne. A copy of this report was provided via email to Administrator Heather Payne. An electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
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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