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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700362
Report Date: 02/19/2021
Date Signed: 02/19/2021 06:04:40 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:
02/19/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:James Wong and Patricia Wong, LicenseeTIME COMPLETED:
04:42 PM
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An Office meeting was held on this day via WebEx to discuss staffing and COVID related concerns at the facility. Present at the meeting was Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Stephenie Doub and facility representatives James Wong, Patrica Wong, Jade Parker, and Hatixhe Grbeshi. Also in attendance was Jill Peterson and Gorlia Xiong from the Stanislaus County Public Health (SCPH).

On January 12, 2021 the facility notified the Department of one (1) COVID positive case. The last COVID positive case reported was on 1/18/2021. Since the response testing completed on 1/18/2021, there has not been any other testing conducted. Per SCPH, The administrator has reported that the lab has been unreliable, but that none of the staff are positive and residents are not showing any symptoms. It was discussed during this meeting that this was not an acceptable response and that without the response testing it could not be confirmed or denied if the were still COVID positive persons in the facility. SCPH reported that they have offered resources to the Administrator, but the assistance was declined. The RO expressed concerns over the licensees not being aware of the issues regarding testing. The RO requested a line list of COVID positives be provided to CCL and SCPH by Monday noon as well the mitigation plan as soon as possible.
The RO also discussed staffing concerns. The facility representatives denied that there were any staffing concerns at this time. The RO expressed that the facility was utilizing agency staff as their primary staffing source rather than as a back-up staffing source. The RO advised that the facility needs to have a plan to ensure staffing is sufficient at all times.
Facility representatives were reminded repairs to the memory care doors also need to be corrected.that were cited on 2/17/2021.

An exit interview was conducted with James Wong Licensee 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: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
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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