019200474-9-30-2023-15-AS-KNGN-CW7235-20230930170146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200474
Report Date: 09/30/2023
Date Signed: 09/30/2023 05:01:54 PM

Document Has Been Signed on 09/30/2023 05:01 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:	STONERIDGE CREEK PLEASANTON		FACILITY NUMBER:	019200474
ADMINISTRATOR:	EZEKIEL GRIFFIN		FACILITY TYPE:	741
ADDRESS:	3300 STONERIDGE CREEK WAY		TELEPHONE:	(925) 201-4000
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94588
CAPACITY:	828	CENSUS: 780	DATE:	09/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ezekiel Griffin, Executive Director		TIME COMPLETED:	05:15 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 09/30/2023 at 9:00 AM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced required one-year inspection and met with Aman Nagra, Resident Health Services Director, and explained the purpose of the visit. Ezekiel Griffin Executive Director later arrived at 1:10PM. This facility is an independent living part of the Community Care Retirement Communities (CCRC) composed of five separate four story per site plan - The Tahoe, Eldorado, Shasta, Mendocino and Lassen. In addition to these buildings are the Garden Terraces (GT) units - West has three floors and East has two floors. Along the perimeter of the GT units are the Villas (six category townhouses with private garages ranging from 700 sq ft to 2000+ sq ft). LPA observed the Clubhouse is the main building where management/maintenance offices are located. It also includes resident amenities such as the gardens, Bocce ball courts, Yoga studio, Wood shop, Astronomy center, Tennis courts, Safety Kiosk, Dog parks, spa/salon, game/card rooms, billiard room, theater, fitness center, library, restaurant, cafe and dining rooms. Current census is 810 residents with total capacity for 828 residents. Fire clearance was approved for 558 non-ambulatory residents which includes a hospice waiver for four (7) residents. Fire Drill was last conducted on 08/3/23. Emergency/Disaster Plan (LIC 610E) is posted near the reception desk and close to a Lan line phone. LPA reviewed fourteen (10) resident and ten (6) staff files. Staff has fingerprint clearances and are associated to the facility. Resident files contained Admission Agreements, Physicians' reports (LIC 602), Resident Appraisals (LIC 603A), Assessments, Needs/Services plans (LIC 625), Centrally stored medications (LIC 622), Advanced Health Care Directives/DPOA-H/POLST and Transfer Agreement, ID/Emergency information (LIC 601), Consent for Emergency Treatment (LIC 627C), Personal rights (LIC 613), Personal Property & Valuables (LIC621), Telecommunications Device Notification (LIC 9158), LGBT residents' Bill of Rights.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STONERIDGE CREEK PLEASANTON	FACILITY NUMBER: 019200474
	VISIT DATE: 09/30/2023

NARRATIVE

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LPA along with Executive Director inspected ten (10) apartment units in five separate buildings (the Eldorado, Tahoe, Shasta, Mendocino and Lassen) and units in the Garden Terraces/Villas areas. LPA observed apartment units were clean and in good repair. There were grab bars in the bathrooms. Hot water temperatures were measured at 116.0 degrees Fahrenheit (Eldorado); 117.6 degrees Fahrenheit (Tahoe); 113.1 degrees Fahrenheit (Mendocino), 113.3 degrees Fahrenheit Lassen and 110.8 degrees Fahrenheit (Shasta). 119.6 and 118.0 Fahrenheit Garden Terraces and 112.6 Fahrenheit Villa. Apartments have their own washer and dryer for use of the resident.

LPA observed each apartment has a kitchen. Units are equipped with refrigerators, dish washers, stove, washer, and dryer. Lifeline emergency response buttons are in place in each bathroom. Each unit has also a check in button. Signal systems are either pendants that people wear, or they can push a panic button. There is a check in button that people press around 4:38 PM. If they do not check in, staff goes to check on them. Fire extinguishers (approx. 256) located throughout the facility's buildings were last inspected on 03/7/2023. Stryker emergency chairs were located on the second floor of each building for Emergency/Disaster preparedness. The facility has a health services office where people may come if they aren't feeling well, need blood pressure taken, or minimal wound care for surgical wounds. There are 3 large dining rooms and kitchen. Kitchen freezer was observed at zero degrees Fahrenheit, and three (3) refrigerators were at 35 degrees Fahrenheit. Food supply was checked and there is an adequate supply of 2-day perishables and 7-day non-perishables. Kitchen and food preparation areas were observed to be clean and in compliance.

At the Clubhouse, LPA observed a variety of activity rooms such as the library (run by residents), game rooms, movie theater, fitness rooms. Medication room is locked. Medication technicians /Registered nurses have first aid and CPR and annual training. A certified administrator is on site 40 hours a week to oversee business operation.

No deficiencies were observed in the areas that were evaluated. No citations were issued during today’s inspection. Exit interview conducted and a copy of this report provided to Executive Director.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2023

LIC809 (FAS) - (06/04)

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