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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200175
Report Date: 10/20/2021
Date Signed: 10/20/2021 12:47:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211019112425
FACILITY NAME:STONEHEDGEFACILITY NUMBER:
079200175
ADMINISTRATOR:CAROLINE KOORNFACILITY TYPE:
735
ADDRESS:1447 STONEHEDGE DRIVETELEPHONE:
(925) 957-6652
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:3CENSUS: 3DATE:
10/20/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Caroline Koorn, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff sleeping while on duty
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/20/21 at 11:40 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

During investigation, ADM stated to LPA that staff (S1) was on administrative leave since 10/19/21 pending an internal investigation for sleeping while on duty. Another staff (S2) gave ADM a picture of S1 asleep on the night shift. ADM stated she has had several meetings with S1 and S2 since July 2021 regarding work issues as well as S1 sleeping on the job. ADM told S1 that if she sleeps on the job again, she may be terminated.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be SUBSTANTIATED.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20211019112425
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STONEHEDGE
FACILITY NUMBER: 079200175
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited
CCR
85065.6(b)
1
2
3
4
5
6
7
Employees providing night supervision from 10:00 p.m. to 7:00 a.m., as specified in (c) through (f) below, shall be available to assist in the care and supervision of clients in the event of an emergency, and shall have received training...
1
2
3
4
5
6
7
ADM stated S1 has been placed on administrative leave since 10/19/21 and will be terminated based on violation of work policies and procedures after several warnings discussed with S1 since July 2021.
8
9
10
11
12
13
14
This requirement was not met as evidenced by S1 sleeping on the job which posed a potential heath & safe risk to clients in care.
8
9
10
11
12
13
14
Administrator agreed to submit to CCLD a self certification with staff signatures that all staff will be retrained on client's proper care and supervision especially during night shift.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2