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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200175
Report Date: 10/30/2025
Date Signed: 10/30/2025 05:10:30 PM

Document Has Been Signed on 10/30/2025 05:10 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/
DIRECTOR:		MANSFIELD, DENISE EFACILITY TYPE:
735
ADDRESS:1447 STONEHEDGE DRIVETELEPHONE:
(925) 957-6652
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 3CENSUS: 3DATE:
10/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Denise Mansfield, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 10/30/2025 at 1:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Denise Mansfield and explained the purpose of the visit. The facility’s fire clearance was approved for three (3) non-ambulatory and one (1) may be bedridden.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms which 3 bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 116.0 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene supplies were available for clients. There is a minimum of one week supply of nonperishables and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/09/2025. Emergency Disaster Drill was last posted on 11/2024. First aid kit was observed to be complete. Fire drill was last conducted on 10/08/2025
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/30/2025 05:10 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 10/30/2025 at 04:49 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: 10/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in not having S5 associated in Gardina which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2025
Plan of Correction
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Associated and Cleared during visit.

Civil penalty $500.00
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above in by not having S1 health screening on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2025
Plan of Correction
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Administratorwill submit copy of S1's health screening to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2025 05:10 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 10/30/2025 at 04:49 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: 10/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on iinterview and record review, the licensee did not comply with the section cited above in by not having First Aid for S5 on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2025
Plan of Correction
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Administrator will submit S5's First Aid to CCLD by POC due date
Type B
Section Cited
CCR
80072(a)(8)(E)1
Personal Rights
1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview,record review, the licensee did not comply with the section cited above in not having a dr's order on file for C3's hospital bed/bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2025
Plan of Correction
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Administrator will submit copy of C3's dr's order to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: STONEHEDGE
FACILITY NUMBER: 079200175
VISIT DATE: 10/30/2025
NARRATIVE
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Three (3) clients’ records were reviewed. Five (5) staff records were reviewed, and 4 of 5 have current first aid training and associated to the facility. A sample of all three (3) client’s medications were reviewed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/06/2025:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan - Reviewed


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC809 (FAS) - (06/04)
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