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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801977
Report Date: 08/17/2022
Date Signed: 08/17/2022 10:34:55 AM

Document Has Been Signed on 08/17/2022 10:34 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:STOCKSTILL HOUSEFACILITY NUMBER:
216801977
ADMINISTRATOR:NATALIA MEYERSONFACILITY TYPE:
740
ADDRESS:12051 STATE ROUTE 1TELEPHONE:
(415) 663-0722
CITY:POINT REYES STATIONSTATE: CAZIP CODE:
94956
CAPACITY: 8CENSUS: 6DATE:
08/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Natalia Meyerson - AdministratorTIME COMPLETED:
10:32 AM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with administrator Natalia Meyerson. There are 6 residents with 1 under hospice at facility. Facility has activities planned for residents during the day.

LPA arrived at the facility and had her temperature checked and logged into a log. During facility tour on 8/17/2022 with administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 8/2022 at the time of the visit. Sample test of Carbon monoxide detector was found to be operational during this visit. Fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 6/14/2022. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Facility has residents with a special diet which is posted in the kitchen and administrator goes over with staff when there is a change and/or they are first hired. Toxins are stored in a locked garage and under the kitchen sink. Dangerous items were stored inaccessible to clients. Facility hot water temperature in clients' bathroom faucet measured between 114.8 degrees F and 116.0 degrees F in 2 out of 2 faucets within Title 22 acceptable regulations of 105 to 120 degrees F. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Disaster drills are being conducted quarterly.

Continued LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977
VISIT DATE: 08/17/2022
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Infection Control:
Facility has submitted a mitigation program plan that has been approved, and infection control plan has been submitted. Some posters have been placed at entrance and throughout of the facility. Facility has hand sanitizer available; visitors and staff before coming into work have temperature checked. Facility has PPE supply stored in hallway closet. There has been new staff hired and new resident’s admission since COVID. Residents’ medications are stored and locked in the medication cabinet by kitchen area. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Visitors are being allowed. Residents have also available virtual and telephone calls when contacting with family members and others. Staff stated that all required COVID training is on file in addition to N-95 fit testing for staff.

There were no deficiencies cited at this time.

Department is requesting facility to submit the following update documents by 8/24/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance
Copy of last Disaster Drill
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
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