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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200302
Report Date: 07/16/2025
Date Signed: 07/16/2025 04:40:00 PM

Document Has Been Signed on 07/16/2025 04:40 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:STUART HOUSE, THEFACILITY NUMBER:
079200302
ADMINISTRATOR/
DIRECTOR:		PAMELA GREENFACILITY TYPE:
740
ADDRESS:3067 BELFAST WAYTELEPHONE:
(510) 262-0206
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 4DATE:
07/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:PAMELA GREEN, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On 07/16/2025 at 12:35PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Pamela Green, Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/26/2024. First aid kit was observed to be complete.

Continued on LIC809.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: STUART HOUSE, THE
FACILITY NUMBER: 079200302
VISIT DATE: 07/16/2025
NARRATIVE
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Continued from LIC809.

Three (3) residents' file were reviewed and are incomplete. LPA was informed by Administrator that there are no staff files available for review.

LPA observed the following deficiencies:
  • At 12:53pm, LPA observed unlocked laundry room door with chemicals such as awesome cleaner with bleach, laundry detergent and Lysol sanitizer.
  • At 1:05pm, LPA observed unlocked pre poured medication sitting in the family room on a TV tray.
  • At 1:10pm, LPA observed scissors, knives and tools such as screw drivers, box cutter.
  • At 1:20pm, LPA observed during record review residents files incomplete.
  • At 2:15pm, LPA was informed by Administrator that the facility dose not have staff files.
  • At 2:47pm, LPA was informed by Administrator that the facility dose not have staff training's.
  • At 3:22pm, LPA was informed by Administrator has not conducted a disaster drill in a while and has no record of drills conducted.

LPA requested the following documents to be submitted to CCLD by 07/31/2025.
  • Resident Roster
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of appeal rights and this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2025 04:40 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/16/2025 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STUART HOUSE, THE
FACILITY NUMBER: 079200302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not having staff records maintained at the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Administrator agreed to read the regulation and create staff files for each staff member and email a copy to the department by the POC date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not having staff conduct yearly trainings which poses a potential health and safety or personal rights risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Administrator agreed to have each staff member complete yearly training and email a copy of staff record of completion by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2025 04:40 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/16/2025 at 03:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STUART HOUSE, THE
FACILITY NUMBER: 079200302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having tools such as box cutter, screw drivers which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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Administrator locked items and agreed to keep all sharp objects locked at all times. DEFICIENCY CLEARED DURING VISIT.
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unlocked central storage for medications which poses an immediate health risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Administrator locked medication during visit.
Licensee to read regulation and self certify and submit to the department by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2025 04:40 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/16/2025 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STUART HOUSE, THE
FACILITY NUMBER: 079200302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1569.695(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not conducting emergency disaster drills quarterly which poses a potential health and safety risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
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Administrator agreed to conduct a disaster drill, document and email a copy of document to the department no later than the POC date.
Type B
Section Cited
CCR
87467(a)(3)
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current reappraisal needs and service plans, current physician reports, consent for medical treatment and safe guards for residents which poses a potential health and safety risk to persons in care.
POC Due Date: 08/07/2025
Plan of Correction
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Administrator agreed to obtain current reappraisal needs and service plans, current physician reports, consent for medical treatment and safe guards for R1 R2 and R3. Administrator will submit the documents to the department by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2025


LIC809 (FAS) - (06/04)
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