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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002885
Report Date: 11/02/2021
Date Signed: 11/02/2021 01:10:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:STONEBRIDGE CARE FACILITYFACILITY NUMBER:
397002885
ADMINISTRATOR:SANTILLAN, LORNA & DANILOFACILITY TYPE:
740
ADDRESS:555 DEERWOOD AVENUETELEPHONE:
(510) 938-8602
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY:6CENSUS: 1DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Helena Pastrana, CaregiverTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA met with Helena Pastrana, Caregiver (S1).

LPA and S1, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 119.3 degrees in residents bathroom with the S1.
Last Fire Drill conduced dated 8/3/21. Fire extinguisher maintained 10/31/2021.
Fire alarm and carbon monoxide functional. LPA and S1 observed centrally stored medications. LPA observed sharps and toxins locked.
LPA reviewed 4 staff and 1 resident files. Resident emergency contact complete. LPA observed all staff files complete. Administrator Certificate valid until 6/25/2021.
Upon entry, caregiver did not conduct symptom/temperature check until requested by LPA. Sanitizer and masks observed. Thermometer was not observed. When requested, thermometer was in locked cabinet with medications. Sign in sheets were observed to document date and visitors name. Sign in sheets did not include symptom screening for reporting requirements to public health officer and contact tracing.
All persons in facility fully vaccinated LPA observed 30 days PPE supply.
Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with S1 and a copy of report along with appeal rights was provided. .
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: STONEBRIDGE CARE FACILITY
FACILITY NUMBER: 397002885
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited

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87608 (a)(3) Postural Supports
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require ... documentation ... This requirement was not met as evidence by:
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The licensee failed obtain a written order from physician for use of a postural support strap prior. Based on observation, R1 is using a postural support without approval from physician. This poses a potential health risk to residents in care.
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Type B
11/12/2021
Section Cited

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87464 (f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
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This regulation was not met by evidence by: Licensee did not ensure a sign-in policy and thermometer available upon entry for all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing.

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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