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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803394
Report Date: 09/01/2022
Date Signed: 09/01/2022 02:55:13 PM


Document Has Been Signed on 09/01/2022 02:55 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:STAYMAN ESTATES - ALSTONFACILITY NUMBER:
286803394
ADMINISTRATOR:HERNANDEZ, MARIA SOCORROFACILITY TYPE:
740
ADDRESS:115 ALSTON LANETELEPHONE:
(707) 927-3870
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 6DATE:
09/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Maria Hernandez SocorroTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/01/2022 to conduct a Required Year inspection. This inspection was focused on the infection control practices and procedures of this facility. Facility was initially greeted by staff. Administrator, Maria Hernandez Socorro arrived shortly.

LPA toured building and grounds with administrator. Facility was clean and in good repair. All exits and walkways were free obstructions. Exit alarms were working properly. Resident bedrooms were furnished per regulation. Bathrooms had necessary grab bars and non-slip mats. Facility had a sufficient supply of perishable and non-perishable food. Toxins were kept locked and secured. Medication was centrally stored and inaccessible to residents. Facility has sufficient Personal Protective Equipment to support a resident in isolation. Due to current facility census residents could isolate in their own bedrooms if necessary. Facility staff have been N95 fit tested. High touch surface areas are disinfected daily. LPA observed COVID postings and hand sanitizer throughout the facility. Facility was inspected by the fire marshal on 08/31/2022. Fire extinguishers observed were last charged on 08/09/2022.

LPA requested the following documents be submitted to Community Care Licensing within 30 days of today's inspection.

LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan
LIC 308 Designation of Facility Responsibility
Proof of Liability Insurance
LIC 9020 Client Roster

Exit interview conducted with administrator and a copy of this report printed for the facility. No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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