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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 10/01/2020
Date Signed: 10/01/2020 04:10:28 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: 49DATE:
10/01/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Heather Payne, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst Bruce Jacobs conducted a Health and Safety inspection of the facility regarding concerns about financial issues. LPA met the Administrator Heather Payne and explained the purpose of the visit. The facility currently has 49 residents, 22 in memory care and 27 in assisted living. At the time LPA arrived, there were 3 caregivers and a med tech, plus two housekeepers who are trained in care giving. There was also three kitchen staff preparing lunch,

LPA checked the food supplies and determined the food supply was adequate with two days of perishable and 7 days of non-perishables. Interviews with kitchen staff did not disclose any shortages or interruptions in food services delivery to the facility. Staff also indicated no disruptions in paychecks or payroll.

The facility was clean safe and sanitary upon inspection,. The administrator did indicate the facility was contacted by PG&E stating the bill was due/overdue. LA determined that there had not been any disruptions in the utilities to the facility. Staffing levels appears to be adequate. However, the health agency that performs the physicals for new staff also has an outstanding bill and will not examine any new staff until the bill is settled making staffing a potential issues. The Business Officer Manager was not present to provide additional information on bills. However, the Administrator stated that the bills had gone through a management company that is no longer associated with the facility, apparently due to non-payment of services.

The assigned LPA will follow-up with the Administrator to obtain more financial information and documentation. No deficiencies were identified on this visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020
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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