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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920115
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:33:59 AM


Document Has Been Signed on 06/12/2024 11:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:STONERIDGE CARE HOMEFACILITY NUMBER:
345920115
ADMINISTRATOR:MUBEEZI, VIOLETFACILITY TYPE:
740
ADDRESS:7751 STONERIDGE WAYTELEPHONE:
(916) 745-4659
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 1DATE:
06/12/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator- Violet MubeeziTIME COMPLETED:
11:40 AM
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On 06/12/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility announced to conduct a Pre- Licensing visit. LPA met with Administrator, Violet Mubeezi to conduct a Pre- Licensing visit. This application is a change in ownership (CHOW). This address is currently licensed as Agape Home Care, Facility #347004411. Administrator holds a current administrator certificate (#7034316740 with expiration date 09/09/25). The facility currently has one (1) resident during today's inspection. Facility has a fire clearance for six (6) non-ambulatory residents.

LPA and Administrator conducted a tour of the facility. Areas toured include but are not limited to: residents bedrooms which were properly furnished and maintained. LPA toured common bathrooms and observed to be clean and sanitary. The food supply is within compliance, two (2) days of perishable and seven (7) days of non-perishable food items. Smoke and carbon monoxide detectors are operational. The Fire extinguisher was serviced on 12/20/23. Grab bars were present at the toilet and in the shower. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. Facility's temperature was 74 degrees Fahrenheit during inspection. Hot water temperature was observed to be 110.5 degrees Fahrenheit, which is within the required range of 105-120 degree. First aid kit found to be complete. Required postings are posted throughout the facility.

LPA reviewed one (1) resident file and one (1) staff and found that all required paperwork was present. Additionally, LPA provided administrator with a copy of LIC311F, records to be maintained at the facility.

Component III was waived as the current administrator has been administrator for another RCFE licensed by Community Care Licensing (CCL). LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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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