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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 12/08/2020
Date Signed: 05/10/2021 10:32:36 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: DATE:
12/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Heather Payne, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) T. White contacted the facility via telephone to commence a case management on 12/08/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the case management with Heather Payne.

The purpose of the case management telephone visit is to follow up on bed bugs found in the facility.

On 12/07/2020, LPA spoke with Administrator, Heather Payne regarding bed bugs in the facility. Administrator stated on12/03/2020 observed resident rashes and informed LPA Escobar of bed bugs on 12/04/2020 during a non-related phone call. Administrator stated there were 6 residents who were infected by bedbugs. Administrator stated EcoGuard was contacted and inspected facility on 12/04/2020. Administrator stated she is in contact with EcoGuard and is waiting for quote. LPA reminded Administrator of reporting requirements.

Due to the above noted information, the following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Exit interview was conducted with Heather Payne. 809 report; 809D report; and an appeal rights document was given to Heather Payne via email due Covid-19 precautionary measures. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2020
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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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: 12/08/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2020
Section Cited

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87303(a): Maintence and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met as evidence by
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Based on observation and documentation, licensee did not comply with the section 87303(a). On 12/04/2020 Administrator informed LPA Esocabar that there were bed bugs in the facility which poses a potential health and safety risks to residentin 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: 510-566-9324
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2020
LIC809 (FAS) - (06/04)
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