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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200175
Report Date: 12/12/2023
Date Signed: 12/12/2023 06:19:41 PM

Document Has Been Signed on 12/12/2023 06:19 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
E BAY DELTA AC/SC, 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:
12/12/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Rachel Cadigan, Direct Support ProfessionalTIME COMPLETED:
06:40 PM
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On 12/12/2023, at 4:05PM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct Proof of Correction (POC) visit. LPA met with Rachel Cadigan, Direct Support Professional (DSP) and explained the purpose of the visit. Rachel phoned Administrator, Angelica Bonuan, to inform. Angelica says that she will be on her way to the facility in approx. 30 mins, but called LPA back to say that she won't be able to make it due to traffic.

Facility has the following deficiencies that were not cleared:

  • CCR 80066(a)(12)(B) LPA has not received Criminal Record Clearance (LIC 508) for S4 after annual inspection on 11/08/2023 and POC date 12/08/2023.
  • CCR 80066(a)(10) LPA has not received Health Screening (LIC503) for S4 after annual inspection on 11/08/2023 and POC date 12/08/2023.

Civil Penalties for 80066(a)(12)(B) in the amount of $400.00 assessed immediately for the period of 12/09/2023 - 12/12/2023.

Civil Penalties for 80066(a)(10) in the amount of $400.00 assessed immediately for the period of 12/09/2023 - 12/12/2023.

Civil Penalties in the total amount of $800.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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