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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801977
Report Date: 09/16/2025
Date Signed: 09/16/2025 03:00:09 PM

Document Has Been Signed on 09/16/2025 03:00 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:STOCKSTILL HOUSEFACILITY NUMBER:
216801977
ADMINISTRATOR/
DIRECTOR:		NATALIA MEYERSONFACILITY TYPE:
740
ADDRESS:12051 STATE ROUTE 1TELEPHONE:
(415) 663-0722
CITY:POINT REYES STATIONSTATE: CAZIP CODE:
94956
CAPACITY: 8CENSUS: 6DATE:
09/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Natalia Meyerson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. visit of the facility. LPA was welcomed by Administrator Natalia Meyerson. Facility is single story with a loft for staff use only with four (4) resident bedrooms & three (3) bathrooms, with a fire clearance approved for 8 Non-Ambulatory, hospice waiver for 4, and secured perimeter. At today’s inspection there is a total of 6 residents with no residents currently on Hospice.

LPA toured the facility on 9/16/2025 at 8:20 AM with administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on 8/8/2025 at the time of the visit. Facility smoke detectors are hard wired and sound directly to contracted company which are inspected annually, last being 9/12/2025. LPA observed carbon monoxide detectors to be operational during the visit. Facility has a generator that will start if there is a power shut off. Hot water temperature measured between 115.3 degrees F and 117 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 9/16/2025 at 8:50 AM. 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 at the time of the visit. Food is available for residents any time of the day. There are activities schedule for residents' weekly. Toxins are stored in locked bathroom cabinets, locked kitchen cabinet under sink, and garage. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing.

Continue LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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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Document Has Been Signed on 09/16/2025 03:00 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/16/2025 at 11:58 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's Annual record review, the licensee did not comply with the section cited above in 3 out of 6 Residents (R1, R2, & R3) Reappraisals/care plans were not updated per regulations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Licensee/Administrator will review regulation 87463(a),then they will update the reappraisals for residents R1,R2 & R3 and send to CCL/LPA the LIC9098 form ensuring that care plans were updated by POC due date 10/3/2025 to clear deficiency.
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made and record review, Licensee did not comply with the section cited above. LPA observed that 1 of 2 residents did not have start dates, expiration dates, or quantity of medication recorded per regulation in the centrally storage medication log. This poses a potential health and safety rights risk to residents in care.
POC Due Date: 10/03/2025
Plan of Correction
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Licensee to submit an Inservice Training for all facility staff that administer medication. Training to review documentation of centrally stored medication and include: Topic, Trainer, Date, Name/Job Role, and Staff Signatures. Training to be submitted to CCL by POC due date of 10/03/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2025 03:00 PM - It Cannot Be Edited


Created By: Shannan Hansen On 09/16/2025 at 12:08 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)


87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, 1 out of 3 staff records reviewed llacked required first aid certification, the licensee did not comply with the section cited above in two out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's (S1) first aid certification by POC due date of 10/03/2025 to clear citation
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: STOCKSTILL HOUSE
FACILITY NUMBER: 216801977
VISIT DATE: 09/16/2025
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Continued from LIC809

A sample review of five residents & three staff records as well as two resident’s medications was conducted. LPA reviewed a random sample of resident’s files at 9:40 AM on 9/16/2025 and learned that 3 out of 6 residents (R1,R2 &R3) do not have an updated reappraisal/needs/care plan on file (see LIC809D). 6 out of 6 residents have medical assessments at this time as required by Title 22 Regulation.

Medications were centrally stored in a locked medication cabinet in the facility medication room. The Medications of 1 out of 2 residents records of medication counts according to physicians’ directions did not match on 9/16/2025 at 11:15 AM. Centrally Stored Medication Record (CSMR) of 1 out of 2 residents were found to be inaccurate (see LIC 809D).

LPA conducted a sample reviewed of staff records at 10:15 AM on 9/16/2025 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff have received the additional training requirements as per Title 22 Regulations. LPA was presented with proof of CPR & 1st Aid certification for staff; although 1 of 3 staff records reviewed does not have required updated First Aid certification (see LIC809-D). Natalia Meyerson Administrator Certificate # 7004868740 expires on 5/17/2026.

Disaster Drills have been conducted quarterly/in different shift with the last one being on 8/25/2025.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Licensee to update and submit the following documents by 10/3/2025:



LIC 500 Personnel Summary
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC809 (FAS) - (06/04)
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