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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004435
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:19:58 PM

Document Has Been Signed on 05/22/2024 04:19 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:STONYBROOK RESIDENTAL CARE IFACILITY NUMBER:
306004435
ADMINISTRATOR/
DIRECTOR:		BRANDON PENALOSAFACILITY TYPE:
735
ADDRESS:9542 STONYBROOK DRIVETELEPHONE:
(657) 208-1902
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 5CENSUS: 5DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Maria Gladys Framo and Brandon PenalosaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On May 22, 2024, at 10:05am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by House Manager (HM) Maria Gladys Framo. HM Framo contacted Administrator (AD) Brandon Penalosa by telephone around 10:20am to explain the purpose of the visit. AD Penalosa arrived to the facility around 11:45am.

The facility is licensed to operate for two (2) non-ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five client (5) bedrooms, one staff(1) bedroom, two (2) bathrooms, living room, dining room, kitchen, and outside covered patio area. LPA Kim toured indoor and outdoor of the physical plant around 10:30am with HM Framo. There were no bodies of water or obstructions on the premises. There is a fish tank in the living room. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All rooms were inspected: Client Room 1, Client Room 2, Client Room 3, Client Room 4, Client Room 5, and Staff room 1. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured at 112.2 degrees F and 115.5 degrees F. A comfortable temperature of degrees 70 F was maintained in the facility.

LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food supply and emergency water supply was stored in the garage. The facility has one (1) fire extinguisher that was serviced on August 31, 2023, fully charged, and mounted in the living room. The smoke detectors and carbon monoxide were operable. A working telephone (657-208-1902) remains available. First Aid kit was complete and met all the necessary elements.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STONYBROOK RESIDENTAL CARE I
FACILITY NUMBER: 306004435
VISIT DATE: 05/22/2024
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During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility last conducted a fire/safety drill in April 18, 2024 Fire/Safety drills are done quarterly.

LPA Kim conducted an audit of clients #1-#5 service files, and staff #1-#4 personnel files that were all in order and complete. LPA conducted four (4) staff interviews. Four Clients were in a day program and one client was nonverbal so the interviews could not be conducted.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1) the following deficiencies has been observed and citation issued. The facility was not in good repair for the following: Client Room #1 and Client Room #4 had drawers missing knob/handle, and Bathroom #1 windowsill plaster was peeing off. And the cash resource record for 1 client was not accurate..

An exit interview was conducted, and a copy of this report was provided to Administrator Brandon Penalosa.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
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Document Has Been Signed on 05/22/2024 04:19 PM - It Cannot Be Edited


Created By: Edward Kim On 05/22/2024 at 03:48 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: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
800269h)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one out of five client cash resources which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee states they will have better communication with day program collecting receipts. They will attempt to retreive the missing receipt or have day program provide letter to indicate the missing funds were on the day program end. They will send the correction of the POC to CCLD via email: edward.kim@dss.ca.gov by May 31, 2024
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


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Document Has Been Signed on 05/22/2024 04:19 PM - It Cannot Be Edited


Created By: Edward Kim On 05/22/2024 at 03:57 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: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed in Client Room#1 having a dresser missing a knob on the bottom drawer, Client Room #4 had a dresser missing a handle on the 3rd row drawer, and bathroom #1 windowsill had plaster peeling off.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2024
Plan of Correction
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Licensee states they will fix the dresser knob in Client Room#1, the dresser handle in Client Room #4 and the peeling plaster in the bathroom #2 windowsill. Licensee will send photos to CCLD as a corrected POC via email to edward.kim@dss.ca.gov by May 31,2024.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


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