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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004436
Report Date: 03/17/2025
Date Signed: 03/18/2025 12:23:59 PM

Document Has Been Signed on 03/18/2025 12:23 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:
03/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:44 PM
MET WITH:Brandon Penalosa, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 03/16/2025 at 12:42 pm Licensing Program Analyst (LPA) Zina Brown arrived at the facility. At 12:48pm, LPA entered the facility to conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection.LPA met with Brandon Penalosa to discussed the purpose of the visit. The facility is licensed to operate for four (4) ambulatory disabled adults. Currently, the home has (4) clients. The clients are Harbor Regional Center clients. None the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. On 03/11/2025 at 5:32 pm, the facility paid the annual fees online. The facility has liability insurance wit Pennsylvania Manufacture's Association Insurance Company (Policy #3824011419126) effective dates: 10/13/2024 - 10/13/2025.

The facility is a two story home located in a residential neighborhood. The property consists of the following: 4 client bedrooms, 2 storage rooms upstairs, 2 common bathrooms, a pnatry closet, an office area, a den, a living room, a kitchen, dining room, attached garage which houses the washer and dryer with a deep freezer and an outdoor shaded area.

Between the hours 1:45pm - 3:04pm of LPA conducted a records review of (4) client records, (4) staff records, (4) clients Personal & Incidental Records, (4) Client Medication Administration Records and reviewed the facility disaster plan (last conducted February 2025).The facility disaster plan was current and in compliance with Title 22 at the time of visit.

Between the hours of 1:04pm - 1:20pm, LPA and Brandon Penalosa toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed , plenty of dresser and closet space was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105-120F ( Bathroom #1: 107.6 F & Bathroom #2: 109.7F & Kitchen: 108.8F).

Report continues on LIC 809-C.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: STONYBROOK RESIDENTAL CARE II
FACILITY NUMBER: 306004436
VISIT DATE: 03/17/2025
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide detector was observed and operational. Smoke detectors were working properly, fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Outside grounds were toured and no bodies of water were observed. Exits/ Walkways around the home were free of debris and hazards.

During todays visit LPA did observe deficiencies.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 6); LPA observed the following deficiencies:

On 03/17/2025, between the hours of 1:45 - 3:04pm, LPA conducted a records review and observe the following: 2 out 4 staff did not have TB Test results and 3 out 4 staff did not have health screening on file.


Exit interview conducted with Brandon Penalosa, Administrator and a copy of Report and Appeal Rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2025 12:23 PM - It Cannot Be Edited


Created By: Zina Brown On 03/17/2025 at 03:15 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: STONYBROOK RESIDENTAL CARE II
FACILITY NUMBER: 306004436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above for 3 out of 4 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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4
The administrator will submit proof of health screening result for Staff #2, Staff #3, and Staff 4 to the department by POC due date via email at zina.brown@dss.ca.gov
Type A
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above for 2 out of 4 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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The administrator will submit proof of health screening result for Staff #3 and Staff 4 to the department by POC due date via email at zina.brown@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
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