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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 03/01/2021
Date Signed: 05/04/2021 03:42:48 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: 43DATE:
03/01/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Heather PayneTIME COMPLETED:
04:00 PM
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LPA Johnson met with Licensee Heather Payne via telephone to conduct a case management call due to COVID-19 and pre-cautionary measures. This is to clear POC (Plan of Correction) from case management inspection on 2/17/2021. Title 22 regulations: 80087 (a) Buildings and Grounds (two delayed egress doors leading to the main street non-operational/unlocked) is still outstanding and not cleared.

Civil penalties of $100.00 per day, per violation, have been accruing since 2/19/21 for the 80087 (a) Buildings and Grounds citation.

Civil penalties shall be assessed.

Licensee and Administrator are notified that the civil penalties for Title 22 regulations: 80087 (a) Buildings and Grounds citation continues to run and accrue at $100.00 per day, until corrections/repairs are made.

Exit interview was conducted with Administrator where LPA reviewed report. An electronic copy of the report was emailed to the facility to obtain a signature from the Licensee and emailed back to LPA to be filed.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
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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