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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200240
Report Date: 03/13/2025
Date Signed: 03/13/2025 02:06:52 PM

Document Has Been Signed on 03/13/2025 02:06 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:STANTON MANORFACILITY NUMBER:
019200240
ADMINISTRATOR/
DIRECTOR:		JOSE T. REYES JR.FACILITY TYPE:
735
ADDRESS:1309 RUUS LANETELEPHONE:
(510) 785-9932
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jose Reyes JR, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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On 03/13/2025 at 11:30 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Jose Reyes JR, and explained the purpose of the visit. Administrator certificate is current. The facility’s fire clearance was approved for all six (6) may be non-ambulatory.

LPAs toured the facility including inside and out but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which all bedrooms are occupied by the clients and 2 bathroom. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 111.3 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/06/2025. Emergency Disaster Plan was last posted on 03/13/2025. First aid kit was observed to be complete. Fire drill was last conducted on 01/08/2025. Earthquake drill was last conducted on 03/03/2025.

At 11:46 AM, 6 of clients records were reviewed. At 12:44 PM, 5 staff records were reviewed. All staff have current first aid training and are associated to the facility. LPAs reviewed client's P&I money with log and there was no discrepancies observed. LPAs reviewed a sample of client's medications. All records were observed to be complete and up to date.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: STANTON MANOR
FACILITY NUMBER: 019200240
VISIT DATE: 03/13/2025
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THE FOLLOWING DEFICIENCY WERE OBSERVED DURING VISIT:
  • At 11:45 AM, LPAs observed Lysol disinfectant wipes on the kitchen counter by the sink.



The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/13/2025 02:06 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/13/2025 at 01:54 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STANTON MANOR
FACILITY NUMBER: 019200240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a Lysol disinfectant wipes on the kitchen counter by the sink which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Administrator agrees to self-certify, have in-service training with staff, and sumit to CCLD by POC date.

Staff locked the lysol disinfectant wipes during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
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