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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 02/17/2021
Date Signed: 02/17/2021 03:32:11 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: 44DATE:
02/17/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Heather PayneTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson conducted a health and safety check on this day. LPA met with Administrator Heather Payne.

Health and Safety check included overall safety of the facility including Staffing, health of residents and building and grounds

The LPA toured the physical plant to ensure the health and safety of residents in care. The LPA did observe two non operational delayed egress doors located in the Memory Care area. This is an immediate health and safety risks for residents in care both doors do not lock. The LPA requested copies of documented correspondence with the repair company for the doors. The facility did not have documentation, however they provided LPA Johnson with a name and a number for the repair company which was contacted by the facility on 2/16/2021 to get a quote and a Staff schedule to determine coverage.

During today's inspection, LPA was made aware that the facility is using Alegre for staffing 2 staff for the AM shift, 2 for the PM shift and one for the overnight. The facility will be requesting additional staff from Alegre to start on 2/18/2021.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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
VISIT DATE: 02/17/2021
NARRATIVE
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As a result of this inspection, deficiencies were cited on 809-D, per Title 22 Regulations, Division 6.

Deficiencies were observed and given pursuant to Title 22 rules and regulations, Health and Safety codes. Exit interview was conducted with Heather copy of report provided via email due to COVID 19 precautionary measures, with a read receipt to verify the 809 was received. The Administrator is to print out a copy of the report, sign and email back to LPA Johnson, appeals rights provided.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 02/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2021
Section Cited

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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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This requirement was not been met as evidenced by: LPA observed two delayed egress doors leading to the main street non-operational/unlocked This is an immediate safety risk to the residents in care
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POC shall be completed by 2/18/2021 or a plan to repair submitted to the Department by 2/18/2021.

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3