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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801977
Report Date: 10/14/2024
Date Signed: 10/14/2024 01:01:35 PM


Document Has Been Signed on 10/14/2024 01:01 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
SANTA ROSA RO, 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: 7DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Natalia Meyerson, AdministratorTIME COMPLETED:
01:10 PM
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10/14/2024, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. LPA was greeted by Administrator, Natalia Meyerson. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 7 residents in care. Facility approved/cleared for 8 non-ambulatory, hospice waiver for 4, and approved for secured perimeter.

At approximately 9:50am, LPA and Administrator toured the building and grounds. Facility is having construction done for the day, replacing the floors in the kitchen. Administrator notified LPA about the construction at the time of arrival. Administrator called last week to notify LPA they will be having construction on 10/14. LPA was out of office for the week in training (10/7-10/11) and didn't get a chance to get back to facility. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available and were found in a drawer/cabinet in one of the bathrooms. Water temperature in sinks accessible to residents in care were measured at 114.3 and 118.1 which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected August, 2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Sharps were found to be locked and secured in the kitchen drawer. Toxins were found to be located in the garage. Facility has planned activities with games such as puzzles available to residents. Facility has a monthly food menu available. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

continued on LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977
VISIT DATE: 10/14/2024
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Facility does fire drills quarterly with the last one being conducted on 08/27/2024.

At approximately 10:45 am, LPA conducted review of 5 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

At approximately 11:15 am, LPA conducted a review of 5 resident records. All records had the required documentation.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Control of Property

Exit interview conducted with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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