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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200175
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:31:04 PM

Document Has Been Signed on 11/29/2021 02:31 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Edith Nantumbwe and Caroline Navrro TIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a required annual inspection. After discussing the purpose of the visit and verifying that all staff present had received criminal record clearance and were associated to the facility, LPA met and toured the facility inside and outside with lead staff Edith Nantumbwe, after which Director Caroline Navrro arrived at the facility.

The tour included, but was not limited to bedrooms, bathrooms, living room, kitchen, dining room, and outside area. During the tour, the LPA observed a sufficient supply of extra linen and bathrooms contained grab bars and slip-resistant tiles. In the kitchen and in the garage storage, LPA observed a sufficient two (2) day supply of perishable and seven (7) day supply of non-perishable foods. The hot water temperature was in the safe range between 105 and 120 degrees, and a comfortable temperature was maintained throughout the facility. LPA observed that the fire extinguisher had been serviced in June 2021. The LPA observed that medications were centrally stored and properly labeled.

During the LPA's file review, he observed that physician orders were properly maintained. LPA observed that an Emergency Disaster Plan binder is maintained at the facility and adequate emergency disaster supplies were on hand. The emergency drill log indicated that drills are conducted monthly, the most recent of which had been conducted on 10/21/21.

A Type A citation was issued based on LPA observation of cans of paint outside, which posed an immediate health, safety or personal rights risk to persons in care.

Exit interview was conducted and a copy of this report and the Appeal Rights were provided to the administrator.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2021
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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Document Has Been Signed on 11/29/2021 02:31 PM - It Cannot Be Edited


Created By: James Sampair On 11/29/2021 at 02:01 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STONEHEDGE
FACILITY NUMBER: 079200175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 when cans of paint were left outside, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2021
Plan of Correction
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Licensee corrected deficiency during visit by moving paint to locked storage.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021


LIC809 (FAS) - (06/04)
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