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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801331
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:47:05 PM

Substantiated


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
01/02/2024 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240102143242
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: 14DATE:
01/03/2024
UNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Alesha Evans & Jordan Ward, Facility DesigneesTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Licensee did not provide adequate food service to clients in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 09:55AM and met with Facility Designee Alesha Evans. Entrance interview conducted. LPA spoke with Program Director via telephone at 10:23AM. Program Director was unavailable during today's visit, but indicated Facility Designee is authorized to sign today's reports.

During today's visit, LPA interviewed Facility Designee at 09:55AM, took photographs of the centrally stored food supply at 10:08AM, toured this facility and took photographs beginning at 10:13AM, and conducted staff and client interviews at various times throughout the visit between 10:15AM to 12:15PM. The following was then determined:

The complaint alleges that the facility does not have a sufficient quantity of food in various food groups in order to follow the posted facility menu. During the facility tour, LPA observed the posted facility menu, which
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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 3
Control Number 29-AS-20240102143242
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: 01/03/2024
NARRATIVE
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indicates that today's breakfast is bagel with cream cheese and hard boiled egg. However, interviews and observation revealed the facility served pancakes and diced potatoes. For lunch, LPA observed hamburgers and potatoes served. No changes were noted on the facility menu observed in the kitchen. Staff and client interviews revealed that there is a variety of food served and the menu rotates weekly, with a 4-week rotation. Interview also revealed that while typically food is delivered on Mondays and Thursdays, there has not been a food delivery in the past 2 weeks. Management staff have gone out and purchased food to ensure the clients have food available, however, it is not what is indicated on the facility menu. Additionally, regulation does require that each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan. Neither the observed menu nor the food served during today's visit meets this requirement. The facility did have a sufficient supply of non-perishable food and water to meet clients' basic food service needs, however there was not a sufficient supply of perishable fruits and fresh vegetables. LPA observed 1 bag of apple slices, 1 package of cherry tomatoes, and 1 bag of lettuce. Interviews did indicate that typically the facility has additional fresh fruits and vegetables, but hasn't in the past 2 weeks. There had been a Food Service Director, but that person left and the position has yet to be filled. In the interim, the Program Director is covering that role. As the facility had a large supply of frozen and non-perishable goods in the campus common food supply and the last bulk order was for a 2-week period, Program Director indicated that no food supply orders had been submitted last week. During today's visit, Facility Designee submitted an order for food to be delivered tomorrow, however there was not a 2-day perishable supply of fruits and vegetables present at the facility today. Based on interview and observation, there is sufficient evidence to support the allegation, therefore, the allegation that "Licensee did not provide adequate food service to clients in care" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted with Facility Designee Jordan Ward. Today’s reports and appeal rights were reviewed and provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20240102143242
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2024
Section Cited
CCR
85076(d)(1)
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85076 Food Service (d) (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
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Facility Designee placed a food service order during today's visit. Facility Designee agreed to send a copy of the delivery invoice following delivery to CCL. Additionally, Designee agreed to review the facility's menu with the Program Director upon their return to ensure 1/3 of the servings recommended
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Based on observation and interview, the licensee did not comply with the above cited section, as there was only 1 bag of sliced apples, a package of cherry tomatoes, and 1 bag of lettuce, which poses a potential health risk to clients in care.
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are offered each meal.
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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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
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