<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801312
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:06:07 PM

Document Has Been Signed on 04/11/2024 03:06 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/
DIRECTOR:		LENI STAYMANFACILITY TYPE:
740
ADDRESS:2162 WEST PUEBLO AVENUETELEPHONE:
(707) 226-2557
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 5DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Leni Stayman, Licensee/Administrator & Anna Marshall, House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 8:30 AM, Licensing Program Analyst (LPA) Shannan Hansen made an unannounced annual required inspection of this licensed senior care facility. LPA met with Licensee/Administrator Leni Stayman & House Manager Anna Marshall. There are 5 residents, all having diagnosis of dementia, with 4 on Hospice,

At approximately 8:40AM, LPA toured the building and grounds with House Manager 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; although when touring bedrooms room 2 resident uses oxygen and door did not have notice. Staff put sign on door during visit. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closets although during today's inspection LPA observed tool supplies and toxins/ WD-40 in unlocked hallway closet accessible to residents in care, staff replaced lock during visit (see pic & LIC809-D). Water temperature measured 112.4 degrees F. and 113.3 degrees F, within regulation of between 105 and 120 degrees F at faucets accessible to residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Fire extinguishers were last charged 4/3/2024. Smoke and Carbon Monoxide detectors are one unit throughout facility and were found to be in working order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure, although at 9:25am on 4/11/2024 LPA observed pre-poured medication for AM and dinner in covered container in kitchen locked cabinet (see LIC809-D). During tour of grounds of facility LPA & Licensee observed construction of front yard by gardener that contained half cut wine barrel full of water that was to flow around the front in a trench that was dug. Licensee informed they didn’t know and had other gardeners/maintence workers dump water during visit and assured LPA there will not be any standing water in containers accessible to dementia residents in care. Also observed was a side fence (see pics) falling over (see LIC 9102 TV) Licensee will send pictures of proof fence has been fixed).
Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 04/11/2024 03:06 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/11/2024 at 02:10 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: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 5 staff (S1) do not have Health Screening test completed as required. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
1
2
3
4
Licensee to have staff (S1) obtain a Health Screening test and submit copies to Community Care Licensing for review by POC due date 05/3/2024. Licensee to notify CCL if more time is needed.

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: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/11/2024 03:06 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/11/2024 at 02:10 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: 04/11/2024

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
1
2
3
4
Based on LPA 's observation and interview with Licensee facility pre-poured medication for 5 of 5 residents. This is a potential health & safety risk to residents in care.
POC Due Date: 05/03/2024
Plan of Correction
1
2
3
4
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 05/3/2024. This is a repeat of violation from this time last year during annual inspection.
Proof of training to include: date, time, duration, subject, names and signatures of staff.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's interview with House Manager and record review, the licensee did not comply with the section cited above 1 out of 5 resident's (R1) did not have a TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2024
Plan of Correction
1
2
3
4
Licensee to obtain TB test as indicated by House Manager with Hospice nurse and submit to CCL by POC due date 4/25/2024 with statement from LIcensee understanding the regulation to clear POC.
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: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
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: 04/11/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Also observed back gates not containing locks to back property that contained paint cans, gas cans, sharp gardening tools, & sheds without locks containing 2, 5 gallon drums of paint (see pics). Licensee had all items put in sheds and put locks on all fences & sheds during visit.

At approximately 10:15AM, LPA reviewed 5 of 5 resident records. 5 of 5 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; although resident (R1) records did not contain TB test (see LIC 809-D) House mgr arranged hospice to conduct test at next visit. Hospice care plans were up to date for each hospice resident.

At approximately 11:00 AM, LPA reviewed 5 of 5 staff records. Evidence of current first aid for 4 of 5 staff were present ; although staff (S1) did not have proof (see LIC 809-D), CPR trainings were current. All other required training were documented and current. Required Health Screening (LIC503) was also missing for staff S1 (see LIC 809-D).

The Medications of 1 out of 1 resident were found to be given according to physicians’ directions on 4/11/2024 at approximately 1:30 PM. Centrally Stored Medication Record (CSMR) of 1 out of 1 residents were found to be not complete and accurate not containing start dates.

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 conducts quarterly disaster drills with the last disaster drill conducted on 4/1/2024. Administrator certificate for Leni Stayman 6020433740 expires 10/09/2024. LPA reviewed Licensing Information System (LIS) with House Manager who stated that is correct and updated at this time; no need to change any of the information.

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

Continue on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8
Document Has Been Signed on 04/11/2024 03:06 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/11/2024 at 02:26 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: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)

87705(f)(2)Care of Persons with Dementia(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 evidence by:
Deficient Practice Statement
1
2
3
4
During today's visit LPA found, tools, toxins, WD40 etc. in unlocked hallway closet accessible to dementia residents in care (see pics). This is an immediate risk to Health & Safety of residents in care.
POC Due Date: 04/12/2024
Plan of Correction
1
2
3
4
1)Facility to send in written plan they understand regulation and how it will be followed (4/12/2024) Facility placed new lock on hallway closet door during inspection. 2)Facility will conduct and send proof of staff training of regulation as well by POC due date of 5/3/2024. to clear citation.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 04/11/2024 03:06 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/11/2024 at 02:34 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: 04/11/2024

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
1
2
3
4
Based on LPA's record review and interview with House Manager one out of five staff lacked required first aid certification, the licensee did not comply with the section cited above in one out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
1
2
3
4
Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 5/3/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
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: 04/11/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 5/3/2024:

Some documents obtained at visit
LIC 610 Emergency Disaster Plan (if changed)
LIC 9020 Register of Facility /Resident’s
Copy of Administrator’s Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8