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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004436
Report Date: 11/06/2023
Date Signed: 06/20/2024 01:05:10 PM

Document Has Been Signed on 06/20/2024 01:05 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:STONYBROOK RESIDENTAL CARE IIFACILITY NUMBER:
306004436
ADMINISTRATOR:CLIFFORD T VALMEOFACILITY TYPE:
735
ADDRESS:2301 PEPPERWOOD AVENUETELEPHONE:
(562) 498-4413
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 4CENSUS: 4DATE:
11/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:ADMINISTRATOR BRANDON PENALOSATIME COMPLETED:
02:30 PM
NARRATIVE
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***This report serves as an amendment to clarify LIC 421BG accompanied by this report. It does not supersede the complaint investigation findings reflected on the report created on 11/06/23 LIC 809.***

On 11/06/2023 around 01:00pm Licensing Program Analyst (LPA) Jose Calderon initiated an unannounced Case Management visit - Incident to the above said facility Stonybrook Residential Care 2. Today’s visit was conducted in-person with Administrator Brandon Penalosa.

The LPA Calderon requested a copy of facility LIC 500. Case Management visit was due to staff member not associated with facility.

An exit interview was conducted with Administrator Brandon Penalosa and a hard copy was provided via email for signature.

Note: Amended LIC 809 and LIC 421BG were signed by Cesar Eguilos on 06/20/24.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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Document Has Been Signed on 11/06/2023 02:19 PM - It Cannot Be Edited


Created By: Jose Calderon On 11/06/2023 at 01:47 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STONYBROOK RESIDENTAL CARE II
FACILITY NUMBER: 306004436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2023
Section Cited
CCR
80019(e)(3)

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80019 Criminal Record Clearance (a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) This requirement is not met as evidenced by:
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Administrator shall ensure that all staff are associated to the facility.
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Based on interviews, observations and records the licensee failed to ensure that the staff member is associated to the facility. This poses a potential health & safety risk to
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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:Eva M Alvarez
LICENSING EVALUATOR NAME:Jose Calderon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023


LIC809 (FAS) - (06/04)
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