397002885-11-21-2022-27-AS-APAA-CLDPMW-20221121102702

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397002885
Report Date: 11/21/2022
Date Signed: 11/21/2022 10:27:16 AM

Document Has Been Signed on 11/21/2022 10:27 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	STONEBRIDGE CARE FACILITY		FACILITY NUMBER:	397002885
ADMINISTRATOR:	SANTILLAN, LORNA & DANILO		FACILITY TYPE:	740
ADDRESS:	555 DEERWOOD AVENUE		TELEPHONE:	(510) 938-8602
CITY:	LATHROP	STATE: CA	ZIP CODE:	95330
CAPACITY:	6	CENSUS: 0	DATE:	11/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Danilo Santillan		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Arielle Pascua arrived at the facility on 11/08/2022 at 12:30pm to conduct an unannounced annual visit. Upon arrival LPA Pascua rang the door bell and there was no answer at the door. LPA Pascua called the facility number on file and spoke Administrator, Lorna Santilan. LPA Pascua notified AD Santilan that she was in front of the facility to an annual visit. AD Santilan stated that she was not in town and that she did not have any residents at this time. LPA Pascua will return at another time to complete the annual visit. Licensing Program Analyst (LPA) Arielle Pascua arrived at the facility on 11/08/2022 at 12:30pm to conduct an unannounced annual visit. Upon arrival LPA Pascua rang the door bell and there was no answer at the door. LPA Pascua called the facility number on file and spoke Administrator, Lorna Santilan. LPA Pascua notified AD Santilan that she was in front of the facility to an annual visit. AD Santilan stated that she was not in town and that she did not have any residents at this time. LPA Pascua will return at another time to complete the annual visit. On 11/21/2022 at 9:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual infection control visit. LPA Pascua met with Facility Designated Administrator, Danilo Santillan and explained the purpose of the visit. The Adminstrator's to this facility have active certificates, #600364470 and #600384470 and expire on 04/27/2023 and 06/25/2023. This facility does not currently have any residents in care. There was one other staff member present, Helena Pastrana. This facility has a centralized screening point at the front entrance and is equipped with hand sanitizer and masks. This facility also holds a 30-day suppy of PPE. At 9:45am, LPA Pascua initiated a tour with FDA D. Santilian. A tour of the kitchen was toured. LPA Pascua reminded the Administrator that once a resident has been admitted into care that food supply must be available. Knives and toxins were observed to be locked. Fire extinguishers appeared to have been annually inspected by A.B.C. Fire Protection on 06/24/2022. First Aid Kit was present and contained all of the required components.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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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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
	VISIT DATE: 11/21/2022

NARRATIVE

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This facility holds medication under the kitchen cabinet sink. Due to the facility not having any residents, there was no medication on site at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. Grab bars were observed to be stable and in good repair at this time.
A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.
A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time. LPA Pascua toured the live-in staff bedrooms and bathrooms.
Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
A tour of the garage was conducted. A washer and dryer were identified. All cleaning supplies were locked and made inaccessible to residents at this time.

The following forms and documents were requested to be updated and submitted into CCL
-LIC 308
-LIC 400
-LIC 500
-LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Appeal rights were printed and a copy was given to the facility designated Administrator.

Exit Interview.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/21/2022 10:27 AM - It Cannot Be Edited

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: 11/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited since the window screens were not in good repair in several bedrooms and in the sliding glass door andresidents may not open their windows without pests entering the facility, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2022
	Plan of Correction
1 2 3 4	Licensee agrees to purchase a window screennd send the receipt and picture in to the LPA's email by 12/16/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC809 (FAS) - (06/04)

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