079200820-12-29-2023-15-AS-LAWN-CYZ2VW-20231229164438

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200820
Report Date: 12/29/2023
Date Signed: 12/29/2023 04:44:50 PM

Document Has Been Signed on 12/29/2023 04:44 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: 5	DATE:	12/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Debbie Rubillos, Caregiver		TIME COMPLETED:	05:00 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 12/29/2023 at 10:35AM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Debbie Rubillos and explained the purpose of the visit. Debbie phoned the Licensee, Josefina "Penny" Gardner to inform. Penny arrived at the facility approximately 11:40AM. The Administrator, Andrew Gardener, was not available. The facility’s fire clearance was approved for a resident capacity of 6 Non-Ambulatory. Hospice waiver approved for 6 residents. Administrator's Certificate #6054460740 Expires 01/05/2024. Penny gave Debbie Rubillos authorization to sign report. LPA toured facility with Penny 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 small room offside the dining room 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 72 degrees Fahrenheit. LPA 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 108.8 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. LIC809-C Continued...

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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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Document Has Been Signed on 12/29/2023 04:44 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: 12/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 in by not having prescription insulin medication inaccessible to residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/30/2023
	Plan of Correction
1 2 3 4	Administrator agreed to read the regulation and self certify that they read and understand the regulation moving forward. During visit Administrator removed the insulin and locked the insulin in a toolbox in the refrigerator located in the garage.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/29/2023 04:44 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: 12/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

(c) All RCFE staff who assist residents...shall receive initial and annual training. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not having S2 and S7 First Aid and CPR Training available which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit First Aid and CPR Training to CCLD by POC due date.

Type B

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in not having hospital 1/2 bed rail doctor's orders for R1, R2 and R3 who are not on hospice care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Administrator agreed to obtain doctor's orders for hospital half-bed rails for R1, R2 and R3 and submit 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: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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: 12/29/2023

NARRATIVE

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LIC809-C Continued...

Smoke and carbon monoxide detectors were in operating condition during visit. New fire extinguisher were purchased 06/13/2023. Emergency Disaster Plan was last posted on 10/02/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/02/2023.

At 10:50AM, LPA reviewed 5 residents records. At 12:00PM, LPA reviewed 7 staff records and 5 of 7 have current first aid training and associated to the facility.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 1:16PM LPA observed prescription insulin located in refrigerator unlocked

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 CCLD by 01/05/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
Liability Insurance

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: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC809 (FAS) - (06/04)

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