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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700472
Report Date: 12/08/2021
Date Signed: 12/08/2021 05:32:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:VILLAS AT STANFORD RANCH, THEFACILITY NUMBER:
342700472
ADMINISTRATOR:TYNES, GRAYSONFACILITY TYPE:
740
ADDRESS:1430 W STANFORD RANCH RDTELEPHONE:
(916) 741-7050
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:150CENSUS: 86DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Grayson Tynes, Executive DirectorTIME COMPLETED:
02:14 PM
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On December 8, 2021, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a Required Annual Inspection. LPA met with Grayson Tynes, the executive Director, and informed him the reason for the visit. Prior to the inspection, LPA completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19, contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Mask

Grayson and LPA completed the inspection tool questionnaire with no issues or advisories to report. LPA also combined the 14 day follow up regarding Covid-19 in with this inspection. The facility has no Covid-19 positive residents at this time. The next test date will be There are no staffing issues or PPE needed.

Administrator certificate is valid. and expires on 9/2/2022 Smoke and carbon monoxide detectors are operational. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged and the Facility temperature measured 74 degrees F.
Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Medications are properly stored and locked away.

As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6.


To continue see 809 C...

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: VILLAS AT STANFORD RANCH, THE
FACILITY NUMBER: 342700472
VISIT DATE: 12/08/2021
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The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing later than January 8,, 2022.

Exit interview conducted and a copy of this report given to Grayson.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC809 (FAS) - (06/04)
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