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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801312
Report Date: 04/07/2023
Date Signed: 04/07/2023 03:18:47 PM

Document Has Been Signed on 04/07/2023 03:18 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: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: 6DATE:
04/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee Leni Stayman & House Manager Anna MarshallTIME COMPLETED:
03:25 PM
NARRATIVE
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At approximately 8:45 AM, Licensing Program Analyst (LPA) Shannan Hansen made an unannounced annual required inspection of this licensed senior care facility. LPA met with Licensee Leni Stayman & House Manager Anna Marshall. At approximately 9:00AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. During kitchen inspection LPA observed knives & seizors in unlocked drawers(see LIC809-D) Toxins are stored in a locked storage closet although during today's inspection LPA observed cleaning/disinfecting supplies in unlocked closet.(see LIC809-D). Water temperature measured 121.1 degrees F.,out of regulation between 105 and 120 degrees F at faucets accessible to residents (see LIC809-D). Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Facility has fire pull stations. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure, although LPA found pre-poured medication in kitchen locked cabinet (see LIC809-D).

At approximately 10:15AM, LPA reviewed 3 of 6 resident records. 6 of 6 records contained current and signed admission agreements and physician's orders on file. Medication records are thorough and contained physician's orders for each resident. Hospice care plans were up to date for each hospice resident. LPA interviewed 2 residents during this inspection.

At approximately 11:00 AM, LPA reviewed 3 of 6 staff records. Evidence of current first aid and CPR training were current. All staff either had Covid-19 vaccination documents or exemptions on file. TB test results were missing from 4 staff records (see LIC9102 TV) LPA interviewed 2 staff during this inspection.

Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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Document Has Been Signed on 04/07/2023 03:18 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/07/2023 at 12:46 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: STAYMAN ESTATES-WEST PUEBLO
FACILITY NUMBER: 286801312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview conducted with Licensee they pre-poured medication for 6 of 6 residents. This is a potential health & safety risk to residents in care.
POC Due Date: 04/10/2023
Plan of Correction
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Licensee to transfer medication by 04/07/2023 to original containers and submit a statement they completed this as proof to LPA....
Licensee to train all staff on the regulation 87465(h)(5). Licensee to submit a copy of proof of training to Community Care Licensing by POC due date 05/02/2023
Proof of training to include: date, time, duration, subject, names and signatures of staff.
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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2023 03:18 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/07/2023 at 02:09 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: STAYMAN ESTATES-WEST PUEBLO
FACILITY NUMBER: 286801312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 in finding a knife & scissors in unlocked kitchen drawers, which poses an immediate health, safety or personal rights risk to persons in care. Photos taken.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator to ensure that all sharp objects are stored in a locked storage inaccessible to residents at all times. Administrator to submit an LIC 9098 self certification that all items that can constitute danger to residents have been made inaccessible with a written statement signed by staff that staff understands this regulation to CCL by POC of 04/10/2023.
Type A
Section Cited
CCR
87705(f)(2)
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 in finding comet and alcohol spray in unlocked closet & on back porch, which poses an immediate health, safety or personal rights risk to persons in care. Photo's taken.
POC Due Date: 04/10/2023
Plan of Correction
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Caregivers to lock toxins to be inaccessible to dementia and all residents in care. Administrator to conduct an in-service training regarding dementia regulation and submit LIC 9098 with date of training to CCL by POC date 4/10/2023.

Licensee provide proof of training, topics, date, time, and signatures of participants by fax to CCL by POC date 4/19/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/07/2023 03:18 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/07/2023 at 02:31 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: STAYMAN ESTATES-WEST PUEBLO
FACILITY NUMBER: 286801312

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)

87303(e)(2) Maintenance & Operation. Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F. This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not have hot water temperature between 105 & 120 F in 1 out of 2 resident's bathrooms which poses an immediate Health, Safety risk for residents in care. LPA toured the facility and observed that 1 of 2 hot water temperature was 121.1 degrees F.
POC Due Date: 04/10/2023
Plan of Correction
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Licensee to ensure water temperature is maintained within regulation of 105 TO 120 F. Facility to begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 4/14/2023.
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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023


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: STAYMAN ESTATES-WEST PUEBLO
FACILITY NUMBER: 286801312
VISIT DATE: 04/07/2023
NARRATIVE
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At approximately 12:30 PM, LPA reviewed the facility emergency disaster plan with staff. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 03/13/2023

Administrator certificate is being changed to Licensee's Leni Stayman which expires 10/09/2024.

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


Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LPA received documents at visit:
LIC 500- Personnel Report
LIC 610 Emergency Disaster Plan
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance

Grant Deed / Trust Deed/ Control Of Property.

Copy of Administrator Certificate


with required documents Licensee will be sent to CCL with LIC200
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
LIC809 (FAS) - (06/04)
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