306004435-5-31-2023-22-AS-SHAD-CSCV5B-20230531160739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004435
Report Date: 05/31/2023
Date Signed: 05/31/2023 04:07:46 PM

Document Has Been Signed on 05/31/2023 04:07 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 I		FACILITY NUMBER:	306004435
ADMINISTRATOR:	BRANDON PENALOSA		FACILITY TYPE:	735
ADDRESS:	9542 STONYBROOK DRIVE		TELEPHONE:	(657) 208-1902
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 5		CENSUS: 5	DATE:	05/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Maria Gladys Framo, Brandon Penalosa		TIME COMPLETED:	04:20 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	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff #1 (S1) Maria Gladys Framo and discussed the purpose of the inspection. Administrator (AD) Brandon Penalosa arrived during the inspection. LPA reviewed Infection Control requirements. At about 1:15PM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure. This is a one-story home. Facility is a 6-bedroom, 2-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed 3 staff and 5 clients present at the facility. Client Bedrooms. The 5 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Staff Bedrooms. LPA inspected the staff bedroom. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 106.8 and 116.9 F degrees. LPA inspected all rooms in the facility. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the garage and under the kitchen sink. Medication cabinet is locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 2:00PM, LPA reviewed 5 client files and 5 staff files, interviewed 5 clients and 3 staff, inspected medications for 5 clients, and inspected client money and ledgers for 5 clients.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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 05/31/2023 04:07 PM - It Cannot Be Edited

Created By: Sean Haddad On 05/31/2023 at 03:27 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
, 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: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and records, the licensee did not not conduct quarterly emergency drills and only conducted them twice a year, which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/07/2023
	Plan of Correction
1 2 3 4	Licensee stated they will conduct an emergency disaster drill and submit proof to LPA by POC due date and will conduct them quarterly moving forward.

Type B

Section Cited

CCR

85165(b)(2)

Emergency Intervention Staff Training

(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records and interview, the licensee did not ensure 5 staff have a current CPI certificate, which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Licensee stated they will enroll staff in CPI training and submit proof of enrollment to LPA 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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Sean Haddad

LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: 05/31/2023

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During the inspection, LPA and AD observed the following: the facility has been conducting emergency disaster drills twice a year instead of quarterly and 5 staff did not have current CPI training. LPA provided technical assistance regarding Emergency Disaster Plan and Infection Control Plan.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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