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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004436
Report Date: 04/19/2024
Date Signed: 04/19/2024 02:59:44 PM

Document Has Been Signed on 04/19/2024 02:59 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:STONYBROOK RESIDENTAL CARE IIFACILITY NUMBER:
306004436
ADMINISTRATOR/
DIRECTOR:
CLIFFORD T VALMEOFACILITY TYPE:
735
ADDRESS:2301 PEPPERWOOD AVENUETELEPHONE:
(562) 498-4413
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 4CENSUS: 4DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:54 PM
MET WITH:DSP Sherly RodriguezTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 04/19/24 Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with DSP Sherly Rodriguez as the purpose of the visit was explained. The facility is licensed to serve (4) ambulatory developmentally disabled adults. Current census is (4), clients are linked to the Harbor regional center. Staff was provided upcoming facility fees info. (due date: 04/27/24 $1,816).

The facility is a two-story structure located in a residential neighborhood and consists of the following: six (6) resident bedrooms, two (2) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. Kitchen was inspected and observed to be clean and operational. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients. Emergency water supply is found in the garage. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. No bodies of water nor weapons are on the premises.

LPA conducted a records review of 2 staff records, 2 client records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Carbon monoxide and smoke detectors are interconnected and operational, there are 2 fire extinguisher fully charged.

Exit interview conducted with DSP Sherly Rodriguez, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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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