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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801331
Report Date: 07/09/2025
Date Signed: 07/09/2025 05:35:21 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
03/26/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20250326151315
FACILITY NAME:STONEHENGEFACILITY NUMBER:
565801331
ADMINISTRATOR:LISA OVIEDOFACILITY TYPE:
735
ADDRESS:1758 SOUTH LEWIS ROADTELEPHONE:
(805) 383-3669
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:15CENSUS: 15DATE:
07/09/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:McKian NielsenTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Staff do not treat resident with dignity or respect.
Staff did not follow admission procedures prior to accepting resident into care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint investigation today with the purpose of investigating the allegations noted above. Upon arrival, the LPA met with Administrator, McKian Nielsen and explained the reason for the visit. Entrance interview conducted.

During the initial visit on 04/03/2025, between 2:15pm and 3:45pm, LPA Arroyo conducted interviews with two staff and one resident, conducted a resident file review, and obtained copies of pertinent documents relevant to the investigation. During today’s visit, between 02:30 p.m. and 03:30 p.m., LPA Arroyo conducted interviews with two staff and four residents and obtained copies of pertinent documents.

Report Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
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-20250326151315
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: 07/09/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff do not treat resident with dignity or respect. It was reported that Resident #1 (R1) is being discriminated against and threatened to be kicked out of the facility. Interviews conducted with staff revealed that certain staff have a tendency to speak condescendingly to residents, which negatively impacts the residents experience. Additionally, there appears to be a pattern of favoritism, with certain residents receiving preferential treatment over others. Interviews conducted with residents reinforced these concerns; several reported that specific staff members address them disrespectfully, particularly when requesting assistance with daily tasks around the facility. Many residents expressed feelings of harassment and being singled out by these staff members. Additionally, residents observed instances where the same staff displayed disrespectful behavior toward other residents. Based on the information obtained and reviewed, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff do not treat resident with dignity or respect” is deemed Substantiated at this time.

It was also alleged that staff did not follow admission procedure prior to accepting a resident into care. It was reported that Resident #1 (R1) had not been properly assessed or admitted into the facility. During records reviewed, the LPA did not observe a medical assessment for R1 in the file. Interviews conducted with staff revealed that the admissions protocol is consistent for all residents. A standardized admissions packet is completed for each resident upon admission. Additionally, if a resident is transferred from one facility to another within the same company, a new admissions packet is completed for the resident for the new admitting facility. However, the LPA informed staff that R1’s medical assessment was missing from the file and facility staff was unable to provide a copy of R1’s medical assessment that was dated within the past year at the time of the visit. Based on the information obtained and reviewed, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff did not follow admission procedure prior to accepting a resident into care” is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250326151315
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: 07/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2025
Section Cited
CCR
80072(a)(1-3)
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each client shall have personal rights which include but are not limited to be accorded dignity in his/her personal relationships with staff & to be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature. This requirement was not met as evidenced by:
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The Administrator has agreed to have an in-service training with all staff which focuses on resident’s personal rights and submit proof to CCL no later than POC due date.
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Based on interviews, the licensee did not comply with the section cited above as residents feel harassed and disrespected by certain staff, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/18/2025
Section Cited
CCR
80069(b)(1)
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In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained. This requirement was not met as evidenced by:
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The Administrator agreed to obtain a medical assessment for resident and submit proof to CCL no later than POC due date.
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Based on record review, the Licensee did not comply with the section cited above as R1’s file is missing their medical assessment, and staff was unable to provide a copy during the initial visit, which poses a potential health, safety or personal rights risk to persons in care.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3