306004435-5-6-2026-22-AS-RMRT-DTTVW2-20260506164713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004435
Report Date: 05/06/2026
Date Signed: 05/06/2026 04:47:30 PM

Document Has Been Signed on 05/06/2026 04:47 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 I		FACILITY NUMBER:	306004435
ADMINISTRATOR/ DIRECTOR:	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:	05/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Brandon Penalosa, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 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	Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by House Manager, Gladys Framo. LPA met with Administrator (AD) Brandon Penalosa and explained the purpose of the visit. The facility is a six bedroom, two bathroom, single story residence with an approved fire clearance of four ambulatory and two non-ambulatory clients. The facility currently has a census of five clients in care. Upon entry at 1pm, one client was in the facility and the remaining four were at Day Program. All clients arrived home by 2:30pm. The facility was a comfortable 76 degrees Fahrenheit and an aquarium was observed in the living room with fresh water fish LPA toured the kitchen and observed appliances were in working order. A menu was posted on the refrigerator and there were two days of perishable supplies on hand and seven days of non-perishable supplies in a hallway pantry and in the garage. Sharps and knives were secured in a drawer and chemicals/hazardous material were locked under the sink and in the garage. Emergency supplies of water and food were also in the garage with a washer and dryer; which were operational. LPA toured client rooms and rooms had clean linens and the required furnishings. LPA inspected the hot water in two of two client bathrooms. The hot water temperature ranged from 113.0 to 115.5 degrees Fahrenheit. Bathrooms were clean and grab bars and non skid flooring were observed. Fire alarms and smoke alarms were inspected and both were operational. A fire extinguisher was charged on November 19, 2025. The facility has not conducted a quarterly fire drill. A deficiency will be cited. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 05/06/2026 04:47 PM - It Cannot Be Edited

Created By: RoseMarie Ruppert On 05/06/2026 at 04:09 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: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(c)

Client Medical Assessments

(c) The medical assessment shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review and interviews, the licensee did not comply with the section cited above in one of five clients which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2026
	Plan of Correction
1 2 3 4	AD has requested a copy of the current Medical Assessment from September 2025 and will email LPA the document and place in client file by POC due date.

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 LPA observation, file review and interviews, the licensee did not comply with the section cited above for five of five clients in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2026
	Plan of Correction
1 2 3 4	AD and House Manager will conduct a quarterly fire drill and will email LPA documentation 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.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	RoseMarie Ruppert
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STONYBROOK RESIDENTAL CARE I	FACILITY NUMBER: 306004435
	VISIT DATE: 05/06/2026

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(Continued from LIC 809)

LPA toured the exterior of the property and observed a shaded seating area and a large grassy area for clients to be outside. There are no hazards or obstructions in pathways. A parakeet also is outdoors for the clients to take care of.

LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA reviewed three of three staff training and fingerprint records and conducted a complete review of client records. One of five clients was missing a current Medical Assessment; which was conducted in September 2025. A deficiency will be cited. Client P&I records were reviewed and were accurate. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on October 25, 2027. LPA also reminded AD that licensing fees will be due.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Brandon Penalosa, Administrator (AD) and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: RoseMarie Ruppert
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

LIC809 (FAS) - (06/04)

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