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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200240
Report Date: 01/29/2023
Date Signed: 01/29/2023 12:37:13 PM

Document Has Been Signed on 01/29/2023 12:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:STANTON MANORFACILITY NUMBER:
019200240
ADMINISTRATOR:JOSE T. REYES JR.FACILITY TYPE:
735
ADDRESS:1309 RUUS LANETELEPHONE:
(510) 785-9932
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
01/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Marlon Ampler, CaregiverTIME COMPLETED:
12:45 PM
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On 01/28/2023 at 11:40AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Marlon Ampler, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Jose Reyes, for document signing approval.

Upon entry, LPA's temperature was not checked. LPA observe a screening station, and COVID signs on front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA did not observe cough etiquette and physical distancing posted in the common areas due to client's diagnosis facility not able to post. All hand washing stations were equipped with soap and paper towel. LPA recommended step on or automatic trash cans for kitchen and bathrooms. Hot water temperature in the shared clients’ bathroom was measured at 119.1 degrees Fahrenheit. Fire extinguisher last serviced on 1/17/2023. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke/carbon monoxide detector operable.

During record review, LPA observed facility has a copy of the Mitigation plan on file. LPA observed PPE and paper supplies are sufficient.

LPA requested the following documents be submitted to CCLD by 2/6/2023:
  • Facility roster


Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2023
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: STANTON MANOR
FACILITY NUMBER: 019200240
VISIT DATE: 01/29/2023
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Continued from LIC809.
  • Personnel record (LIC500).
  • Administrator certificate.
  • Updated emergency disaster plan (LIC610D)


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2023
LIC809 (FAS) - (06/04)
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