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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200820
Report Date: 02/05/2024
Date Signed: 02/05/2024 12:35:17 PM


Document Has Been Signed on 02/05/2024 12:35 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:STONEHEDGE GUEST HOMEFACILITY NUMBER:
079200820
ADMINISTRATOR:ANDREW GARDNERFACILITY TYPE:
740
ADDRESS:1415 STONEHEDGE DRTELEPHONE:
(925) 957-6813
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 6DATE:
02/05/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Penny Gardner, Administrator TIME COMPLETED:
12:45 PM
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On 02/05/2024 at 10:10 AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted an unannounced Health & Safety inspection. LPA met with Administrator, Penny Gardner.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, medication room, and outdoor area. 7-days of non-perishables and 2-days of perishable food supplies were present. Resident's medications were kept locked in the medication cabinet. Smoke and carbon monoxide detectors are observed throughout the facility and the bedrooms. First-aid kit was complete. Fire extinguisher was observed to be full and last inspected 06/13/2023. No accessible bodies of water were observed. Indoor and outdoor passageways were free of obstruction.

No deficiencies are cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2024
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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