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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004435
Report Date: 05/31/2022
Date Signed: 05/31/2022 12:07:18 PM

Document Has Been Signed on 05/31/2022 12:07 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:STONYBROOK RESIDENTAL CARE IFACILITY NUMBER:
306004435
ADMINISTRATOR:BRANDON PENALOSAFACILITY TYPE:
735
ADDRESS:9542 STONYBROOK DRIVETELEPHONE:
(657) 208-1902
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 5CENSUS: 5DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Roselinda Baccary, caregiver
Maryneilrose Igama, caregiver
Maria Framo, House Manager		TIME COMPLETED:
12:25 PM
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On 05/31/2022 at 10:30am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Roselinda Baccary and Maryneilrose Igama, caregivers present after explaining the purpose of the visit. House manager Maria Framo was notified and arrived later to assist with the visit.

At approximately 10:45am, LPA accompanied by house manager toured the inside and outside of the facility. There are currently five (5) clients in care, two (2) of which are currently out at their respective day programs. Clients are observed relaxing in the common areas or in their bedroom and appear clean and well taken care of. The five (5) single bedrooms include all necessary components. The bathrooms are equipped with grab bars and slip mats. Hand washing signs are being displayed. Facility appears to be clean, sanitary and free of odors in all areas inspected. There are two fire extinguishers, both of which observed to be fully charged and functional.

Sharp instruments are stored in a kitchen drawer with a key lock. Most cleaning supplies are secured in a locked cabinet in the attached garage. LPA observes cleaning products are stored unlocked in a bathroom used by both staff and clients, as well as in the cabinet under the sink which has a non-functional lock LPA observed the facility has COVID-19 Precautions posters and required department postings. Facility has an adequate supply of PPE. LIC808 Mitigation Plan has been submitted. Staff present is adequately cleared in Guardian. A copy of the current Administrator certificate for Brandon Penalosa is requested and provided by staff.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STONYBROOK RESIDENTAL CARE I
FACILITY NUMBER: 306004435
VISIT DATE: 05/31/2022
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CONTINUED FROM FORM LIC809 DATED 05/31/2022

LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility and observed it to be free of obstructions. One of the perimeter gate can be opened without tools or separate keys. There is however a padlock present on the second perimeter gate. Section 1021 of the California Building Standards Code indicates that the facility should have a minimum of two exits, which are present. LPA consulted with administrator to indicate that in case of an evacuation, a locked gate can become a safety risk and that the locked gate should be kept open unless an approved exception has been issued. No bodies of water are observed on the premises.

LPA observes a check-in station in proximity to the facility entry point, which is used for both visitor sign-in and client symptom documentation. No temperature checks for residents are being documented after January 2022. LPA reminds licensee that the surveillance of infection signs among clients is still a requirement, and issues a technical advisory accordingly.

Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. A Technical Advisory is also issued in regard to the documentation of infection control surveillance. This report was reviewed with facility representative and a copy of this report and appeal rights was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2022 12:07 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 05/31/2022 at 11:53 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STONYBROOK RESIDENTAL CARE I
FACILITY NUMBER: 306004435

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)&(i)
California Code of Regulations 80087(g) Buildings and Grounds: "Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients." and (i) "The items specified in Section 80087(g) above shall not be stored in food storage areas or in storage areas used by or for clients."

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 in several instances of unlocked cleaning products which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2022
Plan of Correction
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Licensee agress to keep all cleaning products in a locked location and to replace non-functional locks where applicable.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022


LIC809 (FAS) - (06/04)
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