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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 03/03/2021
Date Signed: 05/04/2021 03:32:54 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: 19DATE:
03/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Heather PayneTIME COMPLETED:
12:30 PM
NARRATIVE
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An Office meeting was held on 3/3/2021 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, and facility representatives Licensee James Wong, and Administrator Heather Payne. Current Census is 19.
Issues discussed during the meeting were:

The facility at the end of each 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 was issued deficiencies on 3/2/21 for building & grounds issues from CCL. The Modesto Fire Department also had four pages of violations from 2/25/21 and has until 3/16/21 to fix or keep LPA Jason Lund advised of the repairs.

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 provided a closure plan to CCL and was informed to follow the plan per Regional Manager (RM) Krystall Moore. The facility closure plan indicated that all residents would be moved to another licensed facility. Administrator Heather Payne stated the facility moved three residents to a room and board. Room and boards are not a licensed facility and does not provide the care and supervision as a licensed facility does.

As a result of this meeting, deficiencies will be cited on 809-D, deficiencies were stated 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: 03/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021
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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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: 03/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2021
Section Cited

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87405 (d)(1) Administrator - Qualifications and Duties
The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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This requirement was not been met as evidenced by: During the meeting Administrator Payne stated that she moved three residents to a room and board. This is an immediate safety risk to the residents in care.
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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: 03/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2021
LIC809 (FAS) - (06/04)
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