286803394-7-13-2021-21-AS-SHAN-C4VNX9-20210713105047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803394
Report Date: 07/13/2021
Date Signed: 07/13/2021 10:50:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	STAYMAN ESTATES - ALSTON		FACILITY NUMBER:	286803394
ADMINISTRATOR:	HERNANDEZ, MARIA SOCORRO		FACILITY TYPE:	740
ADDRESS:	115 ALSTON LANE		TELEPHONE:	(707) 927-3870
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 6	DATE:	07/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Maria Socorro-Hernandez Administrator		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPAs) Hansen & Elliott conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Maria Socorro-Hernandez. Facility has 6 residents present. Facility offers activities of arts & crafts, puzzles and other activities like bingo. During facility tour on 7/13/2021 with Admin Maria Socorro-Hernandez 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 had a tag with no dates punched out. According to administrator it was serviced recently and administrator will forward inspection information to LPA. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. 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. Dangerous items were stored inaccessible to clients in a closet in the kitchen. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Hot water temperatures measured 112.8 degrees F within Title 22 acceptable regulations of 105 to 120 degrees F Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the closet, front office area, and garage. Facility has not hired or admitted anyone new since COVID-19. Residents’ medications are stored and locked in the office. Facility has a 30-day supply of medication for residents. 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. Continued LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: STAYMAN ESTATES - ALSTON	FACILITY NUMBER: 286803394
	VISIT DATE: 07/13/2021

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In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents also have available Facetime and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing. LPAs recommended administrator follow up with agencies that provided training to get proof of training.

In addition, LPAs advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills had been conducted quarterly last being done 7/2020. LPA’s discussed with administrator that disaster drills are still required.

LPA’s had a discussion with administrator regarding visitation guidelines per PIN-21-17. LPA’s confirmed a negative COVID test is not required for visitors. LPAs discussed vaccinated and non-vaccinated visitor guidelines are discussed in the PIN. LPA will forward emailed copy of the PIN to Administrator and Licensee. LPA’s confirmed administrator gets PIN’s automatically via email. LPAs recommended administrator ensure appropriate visitation signs are posted at the facility.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021

LIC809 (FAS) - (06/04)

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