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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700157
Report Date: 05/23/2024
Date Signed: 05/23/2024 10:08:04 AM

Document Has Been Signed on 05/23/2024 10:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CHALET, THEFACILITY NUMBER:
342700157
ADMINISTRATOR/
DIRECTOR:		SUSIE DIZONFACILITY TYPE:
740
ADDRESS:6487 MAIN STREETTELEPHONE:
(925) 787-2740
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 41CENSUS: 20DATE:
05/23/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff, Suzanne DizonTIME VISIT/
INSPECTION COMPLETED:
10:10 AM
NARRATIVE
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On 05/23/24, Licensing Program Analyst (LPA) Talwinder Bains conduced a Case Management visit to conduct health and safety check at facility. LPA met with Staff, S1,Suzanne Dizon and explained the purpose of this visit. Administrator, Susie Dizon was not available and gave permission to S1 to conduct visit with LPA.

During the health and safety check, LPA toured the facility including but not limited to the kitchen, common living areas, dining room, residents’ rooms, and bathrooms. Based on the tour of this facility, the facility appeared to be in good repair.

While doing facility tour and inquiring from staff and residents , LPA found out that there were no weekly menu for residents as required per CCR, Regulation 87555(b)(6) for all facilities serving more than 16 residents, therefore, deficiencies were cited during inspection as indicated on LIC809-D per Title 22 Regulations.

Appeal Rights provided. Exit interview conducted and a copy of the report provided .





SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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Document Has Been Signed on 05/23/2024 10:08 AM - It Cannot Be Edited


Created By: Talwinder Bains On 05/23/2024 at 07:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CHALET, THE
FACILITY NUMBER: 342700157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2024
Section Cited
CCR
87555(b)(6)

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87555-General Food Service Requirements - (b) The following food service requirements shall apply: (6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days...... Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request.
This requirement is not met as evidenced by;
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Administrator shall send a letter of understanding of this Regulation and will post a weekly menu for all residents for 30 days. Facility shall send proof to CCL within 15 days for weekly menus. All POC documents are due by 06/06/24.
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Based of information gathered during facility’s visit on 05/23/24, LPA found out that facility was not providing weekly menus to residents as required per this Regulation which poses a potential health and safety risks for residents in 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:Laura Munoz
LICENSING EVALUATOR NAME:Talwinder Bains
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024


LIC809 (FAS) - (06/04)
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