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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100400622
Report Date: 12/30/2024
Date Signed: 12/31/2024 08:31:47 AM

Document Has Been Signed on 12/31/2024 08:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:STONEHAVEN SENIOR LIVINGFACILITY NUMBER:
100400622
ADMINISTRATOR/
DIRECTOR:		CARTER, BENJAMINFACILITY TYPE:
740
ADDRESS:1717 SOUTH WINERY AVENUETELEPHONE:
(559) 251-8417
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 116CENSUS: 53DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jaycee Sanderson, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On December 30, 2024, Licensing Program Analyst (LPA) Rachel Bruce arrived unannounced to conduct the Annual inspection and Health and Safety check. LPA met with Jaycee Anderson, Administrator (AD) and explained the purpose of the visit. Facility tour was provided by AD.

During this visit, LPA toured the two Assisted Living buildings at this facility. Resident rooms contained required furnishings and lighting. Restroom showers/bathtubs are equipped with shower tile that is non- skid, explaining the absence of Non-skid mats. Room 209 in resident building "HOPE" was lacking a bathroom door, due to damage and accessibility by wheelchair. A curtain was installed for privacy during the visit today, so no citation will be issued. LPA tested the hot water in two resident rooms; temperature measured 112.6 and 110.8 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured and observed to be in good repair with the exception of the door to the walk-in freezer which is broken. Citation issued for that at today's visit. Sharps/knives were properly stored. LPA AD and kitchen staff confirmed that fresh food is delivered weekly. Ice machine was clean, functional and in good repair.

Medications are centrally stored and locked in medication room; there is one in each building. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid supplies are located throughout facility and found to contain required items.

Fire Extinguishers are located throughout the facility and were all serviced in August 2024. Smoke and Carbon Monoxide detectors are tested routinely, batteries are changed every 6 months. Smoke Alarms and sprinklers are checked annually with Mid State fire safety company, last inspection was August, 2024. LPA conducted resident and staff file reviews and interviews.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. An exit interview was conducted and a Plan of Correction was developed.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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Document Has Been Signed on 12/31/2024 08:31 AM - It Cannot Be Edited


Created By: Rachel A Bruce On 12/30/2024 at 12:15 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: STONEHAVEN SENIOR LIVING
FACILITY NUMBER: 100400622

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenace shall include provision of maintenance services and procedures for the safety and well being of resident, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with a malfunctioning door to the freezer compartment located in the kitchen which poses a potential risk to the health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2025
Plan of Correction
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Facility maintenance has recieved the part necessary for repair and will address the repair of the door. Pictures of fixed door will be sent to CCL by the due date of January 6, 2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Rachel A Bruce
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2024


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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: STONEHAVEN SENIOR LIVING
FACILITY NUMBER: 100400622
VISIT DATE: 12/30/2024
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A copy of this report and Appeal Rights were discussed with Jaycee Sanderson, Administrator. A copy of this report and Appeal Rights were discussed and will be sent via email as printer is not functioning.

LPA requested and recieved a copy of the following:
  • Current copy of Administrator Certificate,
  • Liability Insurance,
  • Emergency and Disaster Plan (LIC 610E)
  • Personnel Report (LIC500),
  • Register of Facility Clients/Residents for (LIC9020A).
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC809 (FAS) - (06/04)
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