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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 370808597
Report Date: 11/06/2024
Date Signed: 11/06/2024 03:58:33 PM

Document Has Been Signed on 11/06/2024 03:58 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:STONE MOUNTAIN RANCHFACILITY NUMBER:
370808597
ADMINISTRATOR/
DIRECTOR:		ROBINSON, DEZIFACILITY TYPE:
735
ADDRESS:16585 HIGHLAND VALLEY ROADTELEPHONE:
(760) 789-4600
CITY:RAMONASTATE: CAZIP CODE:
92065
CAPACITY: 15CENSUS: 12DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Program Director Elena OconnorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management visit. LPA was greeted and allowed entry into the facility by Program Director Elena Oconnor and discussed the purpose of the visit.

The facility self reported a client's death on 11/4/2024. On 11/3/2024 Client #1 (C1) passed away in her bed at facility. Today, LPA conducted a health and safety check on clients in care, reviewed records and interviewed staff. No health and safety concerns were observed during today's visit. According to the Program Director, C1 was on hospice.

No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Program Director whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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