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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801977
Report Date: 09/02/2021
Date Signed: 09/03/2021 08:18:51 AM

Document Has Been Signed on 09/03/2021 08:18 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:STOCKSTILL HOUSEFACILITY NUMBER:
216801977
ADMINISTRATOR:NATALIA MEYERSONFACILITY TYPE:
740
ADDRESS:12051 STATE ROUTE 1TELEPHONE:
(415) 663-0722
CITY:POINT REYES STATIONSTATE: CAZIP CODE:
94956
CAPACITY: 8CENSUS: 8DATE:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Natalia Meyerson - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Natalia Meyerson. Facility has 8 residents present. Facility offers activities of music, arts & crafts, puzzles and other activities.

During facility tour on 9/2/2021 with Admin Natalia Meyerson 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 was last charged on 7/2021. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. Facility has a smoke detector system that is connected, and last inspection occurred on 9/15/2020. 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 locked garage, and under kitchen sink. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Facility administrator understands that hot water temperatures must measure 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 a table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the garage and upstairs office room. Facility has hired and admitted new residents and staff since COVID-19. Residents’ medications are stored and locked in the locked armory by the kitchen storage. 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
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977
VISIT DATE: 09/02/2021
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In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available Zoom 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.

In addition, LPA 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 7/2021. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32 & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19). In addition, LPA had a discussion with administrator regarding visitation guidelines per PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19).

LPAs reviewed Licensing Information System (LIS) with staff who stated that is correct and updated at this time.




There were no deficiencies cited at this time.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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