079200820-12-8-2022-15-AS-LAWN-CLWUHY-20221208143642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200820
Report Date: 12/08/2022
Date Signed: 12/08/2022 02:36:59 PM

Document Has Been Signed on 12/08/2022 02:36 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:	STONEHEDGE GUEST HOME		FACILITY NUMBER:	079200820
ADMINISTRATOR:	ANDREW GARDNER		FACILITY TYPE:	740
ADDRESS:	1415 STONEHEDGE DR		TELEPHONE:	(925) 957-6813
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 6	DATE:	12/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Epifania Angcla, RN		TIME COMPLETED:	02:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/08/2022 at 10:35 AM, Licensing Program Analysts (LPAs) L. Alexander and C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Epifania "Nanette" Angcla and explained the purpose of the visit. Nanette called the Administrator, Josefina "Penny" Gardner. Penny arrived approximately at 11:25 AM. LPAs toured facility with including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 77 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. During record review, LPAs observed facility has a copy of the infection control plan on file. LPAs observed food and paper supplies are sufficient. The following deficiencies were observed: At 11:04 AM LPAs observed bleach, Pine-Sol, ammonia, window cleaner, Lysol spray, Pledge cleaner. At 11:05 AM LPAs observed hammer, scissors, screw driver. At 11:06 AM LPAs Tide Laundry Detergent PODS. At 11:08 AM LPAs observed incense, sage, strawberry margarita mix in the garage. At 11:21 AM LPAs observed planks of wood, tools, puddy, paint can, caulking . Continued on LIC809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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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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 GUEST HOME	FACILITY NUMBER: 079200820
	VISIT DATE: 12/08/2022

NARRATIVE

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Continued from LIC809

At 11:23 AM LPAs observed locked gate (Easement exit per Penny).
At 11:24 AM LPAs observed planks of wood, table, blinds, plant soil.
At 11:25 AM LPAs observed concrete, door screens, wood behind shed.
At 11:25 AM LPAs observed locked gate (front).
At 11:26 AM LPAs observed WD-40, saw, hammer, monkey wrench, moving dolly.
At 11:28 AM LPAs observed plant soil by outdoor patio furniture.

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.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/15/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
Monkey Pox Mitigation Plan

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2022 02:36 PM - It Cannot Be Edited

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 GUEST HOME	FACILITY NUMBER: 079200820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(I)(2)

87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by being unable to open the backyard gates which poses an immediate health & safety risk for persons in care.
	POC Due Date: 12/09/2022
	Plan of Correction
1 2 3 4	Administrator agreed to remove the lock on the gate and to submit a picture to CCLD by POC due date. Administrator will complete an In-Service training with Staff and will send a copy with each Staff's signature. Facility is being assess $500 civil penalty for todays visit.

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having bleach, Pine-Sol, ammonia, window cleaner, Lysol Spray, Pledge Spray, hammer, screw driver, scissors, Tide Laundry Detergent PODS which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2022
	Plan of Correction
1 2 3 4	Administrator agreed to store cleaners in locked cabinet and submit photo to CCLD by POC 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 12/08/2022 02:36 PM - It Cannot Be Edited

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 GUEST HOME	FACILITY NUMBER: 079200820
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(A)

87208 Plan of Operation (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by allowing Staff to dwell in a small storage room attached to the home without permits which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2022
	Plan of Correction
1 2 3 4	Administrator agreed to have Staff vacate the storage area and submit a LIC 200 along with an updated facility sketch to request for a new fire clearance to CCLD no later then the POC date.

Type B

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having these items accessible plank wood, table, blinds, potting soil, concrete, door screens, wood, WD-40, saw, hammer, monkey wrench, dolly, paint can, caulking which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2023
	Plan of Correction
1 2 3 4	Administrator agreed to remove plank wood, table, blinds, potting soil, concrete, door screens, wood, WD-40, saw, hammer, monkey wrench, dolly, paint can and caulking by submitting a photo 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.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

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