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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200474
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:25:49 PM


Document Has Been Signed on 08/15/2024 02:25 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:STONERIDGE CREEK PLEASANTONFACILITY NUMBER:
019200474
ADMINISTRATOR:EZEKIEL GRIFFINFACILITY TYPE:
741
ADDRESS:3300 STONERIDGE CREEK WAYTELEPHONE:
(925) 201-4000
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY:828CENSUS: 780DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Ezekiel Griffin, Executive DirectorTIME COMPLETED:
03:05 PM
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On 08/15/2024 at 9:28 AM, Licensing Program Analysts (LPAs) Ardalan Gharachorloo and David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, Ezekiel Griffin and explained the purpose of the visit.

LPAs toured the facility including but not limited to 5 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F. The hot water temperature in a residents apartments' bathroom was measured at 114 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxics are locked and inaccessible to residents in care.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 01/04/2024. Emergency Disaster Plan was last posted on 06/06/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 08/07/2024.

LPAs reviewed 7 residents records and 6 staff records, and all were complete. LPAs also reviewed a sample of resident’s medications.

The following reports were reviewed: LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, Liability Insurance, and Current Administrator’s Certificate.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Ardalan GharachorlooTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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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