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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801312
Report Date: 05/14/2021
Date Signed: 05/14/2021 01:38:23 PM

Document Has Been Signed on 05/14/2021 01:38 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:STAYMAN ESTATES-WEST PUEBLOFACILITY NUMBER:
286801312
ADMINISTRATOR:VILLALUZ, JUAN R.FACILITY TYPE:
740
ADDRESS:2162 WEST PUEBLO AVENUETELEPHONE:
(707) 226-2557
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 5DATE:
05/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ricky VillaluzTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Angela Elliott conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Juan "Ricky" Villaluz and Carol Villaluz. Clients were present at the facility. LPA observed residents in the living room wearing face masks. Other residents were resting in their rooms.

LPA arrived at the facility and had temperature checked and logged into visitor’s binder. During facility tour the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. There was one entry point for the facility. Staff and residents are monitored daily. Facility has submitted a mitigation program plan that has been approved. Postings pertaining to COVID-19 were throughout the facility. Entrance has a small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in a closet in the hallway. Client emergency contact information has been updated and Emergency Personnel numbers are posted at the facility. Clients’ medications are stored and locked in a side room next to the kitchen. Facility has a 30-day supply of medication for clients.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Angela Elliott
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2021
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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