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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 04/01/2021
Date Signed: 04/01/2021 05:33:58 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: 9DATE:
04/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Ataly Vazquez TIME COMPLETED:
03:00 PM
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On 4/1/2021, Licensing Program Analyst (LPA) Jason Lund arrived at the above facility to do a case management visit. LPA Lund spoke with Administrator Ataly Vazquez over the phone and explained the reason for the visit. Current census 0

LPA Lund walked the facility. The facility has no more residents as of 4/1/2021 and did surrender their License to Community Care Licensing. LPA Lund will get an email verification from Licensee Patrica Wong that all residents received all refunds due to the residents in care of the facility.

Exit interview was conducted over the phone with Administrator Ataly Vazquez and LPA Lund emailed a copy of report to Administrator Ataly Vazquez and Licensee Patrica Wong.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
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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