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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 02/10/2021
Date Signed: 02/11/2021 04:07:42 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: DATE:
02/10/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:James Wong & Patricia Wong, LicenseeTIME COMPLETED:
02:00 PM
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An Office meeting was held on this day via Microsoft Teams to discuss the findings of the complaint investigation of the allegation noted above. Present at the meeting was Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Liza King, LPA Stephenie Doub, Auditor Diana Chapman and faciltiy representatives James Wong, Patrica Wong, Jade Parker, Hatixhe Grbeshi, Robert Cantoria and Maria Cantoria.

The purpose of the visit was to discuss the pending sale of facility and the pending change of use due to the sale. The RO advised that the facility needed to submit a closure plan and assist residents in relocation. Per facility representatives, there are 25 memory care residents residing at the facility. The potential new owners will not be able to provide care to those residents as memory care will not be part of their program design. The RO requested that the facility provide a current resident roster, with responsible party contacts to CCL by 2/16/2021. The RO will continue to monitor to ensure proper transition for the current residents in care.

An exit interview was conducted with Facility Representatives and a copy of this report was provided via email. An electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021
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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