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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801331
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:20:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230227141430
FACILITY NAME:STONEHENGEFACILITY NUMBER:
565801331
ADMINISTRATOR:JESUS CARDENASFACILITY TYPE:
735
ADDRESS:1758 SOUTH LEWIS ROADTELEPHONE:
(805) 383-3669
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:15CENSUS: 15DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Ayana ChurnTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Facility staff did not assist client with self-administration of medications
Facility staff does not speak to client with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 11:35AM and met with Program Director Ayana Churn. Entrance interview conducted.

During today's visit, LPA interviewed staff and residents from 12:40PM to 02:38PM. LPA toured the facility during the visit. Previously, on an initial complaint visit conducted on 03/07/2023, LPA interviewed Program Director at 02:20PM, toured the facility with Program Director at 02:46PM, and LPA reviewed and obtained copies of pertinent documents. Throughout the course of the investigation, LPA reviewed pertinent documents. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20230227141430
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: STONEHENGE
FACILITY NUMBER: 565801331
VISIT DATE: 10/25/2023
NARRATIVE
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Allegation: "Facility staff did not assist client with self-administration of medications:"
The complaint alleges that Client #1 (C1) does not receive their medications as prescribed. LPA reviewed the Medication Administration Record (MAR) for C1 and did not note any discrepancies with prescribed medications. Interviews revealed that C1 does remain in bed most of the day and that at the time of the complaint allegation, C1 sometimes did not come out of their room to receive their medications. All clients and staff interviewed were aware of the times medications are administered and clients come to the office to self-administer medications. Staff indicated that C1 requires many reminders and staff regularly go knock on C1's door to remind them of the medication time. Staff stated that when C1 did not come out for their medications and requested their medications late, staff call C1's medical provider to inform them of C1's request to take their medications outside the scheduled time period. Sometimes C1's medical provider approves the late medication administration, however at some point, C1's medical provider informed staff that C1 is aware of the scheduled medication times and procedure and to mark C1's medications as refused if C1 did not arrive during the scheduled time period. LPA attempted to interview C1 during both the initial and subsequent complaint visits, but C1 did not respond to LPA knocking on their door and staff indicated C1 was sleeping. Other clients interviewed indicated that they go to the office to get their medications at their scheduled times and there have been no problems with their medications. Based on interview and record review, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that "facility staff did not assist client with self-administration of medications" is deemed UNSUBSTANTIATED at this time.

Allegation: "Facility staff does not speak to client with dignity and respect:"
LPA interviewed both staff and residents related to this complaint. All clients interviewed reported that the staff are nice and staff speak to them with respect. Clients indicated that they have never heard staff be disrespectful or rude to any of the clients in the facility. Staff interviews revealed that no staff have ever heard any staff be disrespectful or rude to the clients, even when clients are rude or give the staff attitude. Staff to client interactions observed by the LPA during both visits were appropriate and no concerns were noted. Based on interviews, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "facility staff does not speak to client with dignity and respect" is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. A copy of today's report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2