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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 03/02/2021
Date Signed: 03/03/2021 08:49:32 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 MODESTOFACILITY NUMBER:
502700362
ADMINISTRATOR:PAYNE, HEATHERFACILITY TYPE:
740
ADDRESS:808 MCHENRY AVETELEPHONE:
(209) 524-0808
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:120CENSUS: 19DATE:
03/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Administrator Heather PayneTIME COMPLETED:
06:30 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
Licensing Program Analysts (LPAs) Jason Lund and Albert Johnson conducted a case management visit. LPAs met with Administrator Heather Payne and explained the reason for the visit.

During today visit the LPAs, Administrator and potential licensee Gregory Gordon toured the physical plant for the prelicensing visit. During the visit the group observed a dead animal in the basement and the door going to the basement not secured. The facility didn’t have all the keys to the storages and electrical doors to the facility. Many electrical rooms had debree in the electrical rooms and needs to be cleared. One of three tankless water heaters on the second floor was not working. The foundation in the back patio needs to be repaired. This will need to be fixed before change of licenses. Also the city of Modesto Fire Department came to the facility on 2/25/21 and had four pages of violations that need to be repaired before change of licenses.

As a result of this inspection, deficiencies were cited on 809-D, per Title 22 Regulations, Division 6.

Deficiencies were observed and given pursuant to Title 22 rules and regulations, Health and Safety codes. Exit interview was conducted with Heather copy of report provided via email due to COVID 19 precautionary measures, with a read receipt to verify the 809 was received.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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 2
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: 03/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2021
Section Cited

1
2
3
4
5
6
7
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
8
9
10
11
12
13
14
This requirement was not been met as evidenced by: LPAs & Modesto Fire Dept. noted violations to the facility on the LIC 809 and report from Fire Dept dated 2/25/21 what needs to be fixed before change of licenses. This is an potential safety risk to the residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2