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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200175
Report Date: 08/08/2022
Date Signed: 08/08/2022 03:15:18 PM

Document Has Been Signed on 08/08/2022 03:15 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: 2DATE:
08/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Caroline Koorn, AdministratorTIME COMPLETED:
03:30 PM
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On 8/08/22 at 2:15 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a Case Management inspection as a result of a report of a death at the facility. LPA met with Administrator, Caroline Navrro-Koorn and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 111 degrees F in the kitchen sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Refrigerator temperature was observed at 38 degrees F. Resident's medications were kept locked in a med cabinet. Smoke detectors are interconnected with the fire alarm. Carbon monoxide detector observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 4/07/22. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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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