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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200240
Report Date: 03/10/2026
Date Signed: 03/10/2026 12:11:56 PM

Document Has Been Signed on 03/10/2026 12:11 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/
DIRECTOR:		JOSE T. REYES JR.FACILITY TYPE:
735
ADDRESS:1309 RUUS LANETELEPHONE:
(510) 785-9932
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
03/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jose Reyes JR, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 03/10/2026 at 8:30 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a 1-Year Annual Required inspection. LPA 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), who may be non-ambulatory.

LPA 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, all of which are occupied by the clients, and 2 bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. LPAs observed that lighting in all rooms is adequate for the comfort and safety of the clients. The temperature of the hot water in the shared clients’ bathroom was measured at 117.3°F. All toilets, hand washing, and bathing are safe, sanitary, and in operating condition. The supply of extra hygiene products was available for clients. There is a minimum of one week's supply of nonperishable food and a 2-day perishable food supply.

Smoke and carbon monoxide detectors were operational during the visit. The fire extinguisher was last serviced on 1/7/2026. Emergency Disaster Plan was last posted on 01/02/2026. The first aid kit was observed to be complete. Fire drill was last conducted on 01/19/2026. The earthquake drill was last conducted on 01/24/2026.

Continue to LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/10/2026 12:11 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 03/10/2026 at 11:28 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STANTON MANOR
FACILITY NUMBER: 019200240

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2026

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 by Lysol disinfectant wipes and bleach, underneath RM 3 shared bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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The Administrator (ADM) agrees to review and self-certify an understanding of the cited regulation. The ADM will develop and implement a plan to ensure staff maintain frequent room checks for residents. In addition, the ADM will conduct in-service training with all staff regarding the cited regulation and procedures for completing and documenting room checks. Documentation of the training and the self-certification will be submitted to Community Care Licensing Division (CCLD) by the POC due date.

Staff locked the lysol disinfectant wipes and bleach 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Kelly Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


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: 03/10/2026
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Continue from LIC809...

At 9: 00 AM, 6 of the clients' records were reviewed. At 10:00 AM, 5 staff records were reviewed. All staff have current first aid training and are associated with the facility. LPA reviewed the client's P&I money with the log, and there were no discrepancies observed. LPA reviewed a sample of the client's medications. All records were observed to be complete and up to date.

THE FOLLOWING DEFICIENCY WERE OBSERVED DURING VISIT:

· At 11:15 AM, LPA observed Lysol disinfectant wipes and bleach, underneath RM 3 shared bathroom.



- A repeat violation is assessed on today's date of $250.

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

An exit interview was conducted with the Administrator. Appeal Rights, LIC 421FC, and a copy of this report are provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Kelly Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
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