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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 10/28/2020
Date Signed: 05/10/2021 10:27:00 AM

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:
10/28/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Patricia Wang, LicenseeTIME COMPLETED:
03:00 PM
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On 10/28/2020 at 2:00pm, CCLD Sacramento South conducted a conference call with the Licensee. Present in the meeting were Regional Manager Krystall Moore; Licensing Program Manager Czarrina Camilon-Lee; Licensing Program Manager Liza King; Licensing Program Analyst Treana White; Licensing Program Analyst Diego Escobar; JCH Senior Housing Investment Brokerage, Representatives from MGSACT Hatixhe Grbeshi (COO), Patricia Wong (CEO), James Wong, Fred Fucanan Co-owner, Octavia Owens, Gregory Gordon on behalf of the prospective licensee to discuss the potential sale of the facility.

The purpose of this meeting was to review the stipulation that allows time for the current licensee entity to sell or transfer the facility so that the clients do not have to be relocated, assuming that the prospective licensee's application is approved.

Issues discussed at the meeting included, but not limited to:
  • Change of Ownership
  • Facility Purchase Agreement
  • Facility Closure Plan
  • Eviction Notices
  • Facility retention and limitations
Licensee agreed to do the following:
  • CCLD will be provided copies of the eviction notices given to residents and their responsible party.
  • CCLD will be provided copies of the facility's closure plan.

Exit interviewed conducted and copy of report submitted via email. Licensee is to sign and send back to LPA.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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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