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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 03/24/2021
Date Signed: 03/24/2021 12:49:39 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: 6DATE:
03/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Ataly VazquezTIME COMPLETED:
01:00 PM
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On 3/24/2021, Licensing Program Analyst (LPA) Jason Lund arrived at the above facility to do a case management visit. LPA Lund meet with Administrator, Ataly Vazquez and explained the reason for the visit. Current census 6

LPA Lund and Administrator Ataly Vazquez walked the facility. The facility is still removing and going through inventory of the facility and removing unwanted inventory. The facility is continuing to work with a pest control company on getting the bed bugs exterminated. The new licensee has the fire department coming on 3/25/2021 to go over the 4 pages of citations. LPA Lund will continue to do case management visits until the new licensed is issued.

Exit interview was conducted with Ataly Vazquez copy of report provided
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
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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