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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803394
Report Date: 07/30/2024
Date Signed: 07/30/2024 02:50:50 PM


Document Has Been Signed on 07/30/2024 02:50 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: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:
07/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria Hernandez, AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) J Macias arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Maria Hernandez. Facility contact information was reviewed.

At approximately 10:20am LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and dated. Kitchen cabinet containing cleaning supplies was locked underneath sink. Kitchen drawer with sharp knives were locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 112.2 and 111.2 degrees F which is within the allowable range of 105 to 120 degrees F per regulation.

Fire extinguishers were last inspected August 9, 2023. Carbon Monoxide detectors located throughout the facility were tested and operational. Fire Alarm was last inspected on September 6, 2023. Fire Sprinkler System is serviced by an outside vendor and was last inspected on 8/15/2023. Facility’s last quarterly disaster drill was last conducted 7/8/2024.

At approximately 12:30pm LPA conducted a review of five (5) resident records. All required documentation were found to be well organized and complete.

Continued on 809C...
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) -588-8505
LICENSING EVALUATOR NAME: Jacqueline MaciasTELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024
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: STAYMAN ESTATES - ALSTON
FACILITY NUMBER: 286803394
VISIT DATE: 07/30/2024
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Continued from 809...

At approximately 1:30pm LPA conducted review of five (5) staff records. All staff files were found to be complete with all required documentation. First Aid and CPR certifications were all current.

At approximately 2:00pm LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies

Maria Socorro Hernandez Administrator Certificate 7004163740 expires 04/28/2026.


No deficiencies cited during this inspection. Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) -588-8505
LICENSING EVALUATOR NAME: Jacqueline MaciasTELEPHONE: (707) 588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC809 (FAS) - (06/04)
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