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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 10/29/2020
Date Signed: 10/29/2020 02:42:09 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:
10/29/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Heather PayneTIME COMPLETED:
02:47 PM
NARRATIVE
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to commence a case management on 10/29/2020 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 various deficiencies learned throughout a complaint investigation. The following deficiencies were discovered:

The kitchen facility is not in good repair. The facility refrigerator has black stains, food stains, and overgrown frostbite on shelves. Furthermore, the facility freezer has overgrown frostbite. The kitchen walls have black stains, and the kitchen floor is unsanitary. There are scattered food particles and dirt on the floor. Parts of the kitchen floor is missing tiles. As a result, the licensee did not ensure the facility kitchen was clean, sanitary, and in good repair.

Due to the above noted information, the following deficiencies were 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: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
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: 10/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2020
Section Cited

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87303 Maintenance and Operation: (a)The facility shall be clean, safe, sanitary and in good repair at all times....1) Floor surfaces in bath, laundry and kitchen areas shall be maintained...This requirement is not met by:
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Based on facility inspection, the licensee did not ensure the facility kitchen was sanitary. This posed a potential health, safety, & personal rights risk to residents in care.
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The administrator agrees to clean the tile floors in the kitchen by POC date 11/26/2020. Administrator will email LPA repair pictures on 11/26/2020.

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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: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2020
LIC809 (FAS) - (06/04)
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