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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808597
Report Date: 09/21/2022
Date Signed: 09/21/2022 02:11:26 PM

Document Has Been Signed on 09/21/2022 02:11 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:STONE MOUNTAIN RANCHFACILITY NUMBER:
370808597
ADMINISTRATOR:ROBINSON, DEZIFACILITY TYPE:
735
ADDRESS:16585 HIGHLAND VALLEY ROADTELEPHONE:
(760) 789-4600
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 15CENSUS: 13DATE:
09/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Elena O'Connor, Executive DirectorTIME COMPLETED:
11:52 AM
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced case management visit regarding reporting requirements. LPA was granted entry after identifying themselves by Executive Director. LPA discussed the purpose of the visit with Elena O'Connor, Executive Director.

During today's visit, LPA provided guidance on reporting requirements and timely submissions of unusual incidents to the Department as laid out in Title 22, Division 6, Chapter 1, Article 06, section 80061. During an unrelated visit, LPA was told by staff of an incident that was not reported to the Department.

An exit interview was conducted with Executive Director and a copy of this report, along with Licensee/Appeal Rights (LIC9058 03/22), were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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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