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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801331
Report Date: 09/09/2025
Date Signed: 09/09/2025 10:02:46 AM

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
03/11/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20250311092937
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:
09/09/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:McKian NielsenTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff mishandling residents medication.
Staff not administering residents medication as prescribed.
Staff did not properly store medication.
Staff is not adequately trained.
Staff does not provide scheduled activities for residents.
Insufficient staffing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 03/17/2025 by LPAs M. Arroyo and V. Conway, and a subsequent visit was conducted on 07/09/2025 by LPA M. Arroyo. On today’s visit, the LPA met with Administrator, McKian Nielsen. Entrance interview conducted.

During the initial visit on 03/17/2025, the LPAs conducted a plant tour starting at 02:17 p.m., observed the centrally stored medications area and conducted a medications review starting at 02:32 p.m., conducted interviews with two staff at 02:25 and 02:40 p.m., and obtained copies of pertinent documents relevant to the investigation. On 07/09/2025, between 02:30 p.m. and 03:30 p.m., LPA Arroyo conducted interviews with two staff and four clients and obtained copies of pertinent documents relevant to the investigation.

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

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

DATE: 09/09/2025
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 7
Control Number 29-AS-20250311092937
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: 09/09/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff is mishandling residents’ medication and staff is not administering residents’ medication as prescribed. It was reported that there have been medication errors due to facility staff administering wrong dosages and medications not administered as prescribed. A review of clients’ medications and the Centrally Stored Medication and Destruction Records (CSMDR) revealed that medications are properly documented. Staff interviews revealed that while they assist clients with their medications, the clients themselves are responsible for dispensing the medications from the packaging. Staff also added that no clients have reported concerns or experienced any issues related to receiving the wrong medication or dosage. Similarly, client interviews confirmed that they have not encountered any problems with medication administration by staff and expressed no concerns since moving into the facility. Based on the information obtained and reviewed during the course of the investigation, the Department has insufficient evidence to support the allegations of “staff is m mishandling residents’ medication” and “staff is not administering residents’ medications as prescribed”. Therefore, these allegations are deemed Unsubstantiated at this time.

It was alleged that staff did not properly store medication. It was reported that medications are not being properly stored and locked up. During the facility walkthrough, the LPA observed that the medication cart was located inside the Administrator’s office. Although the office was unlocked at the time due to the Administrator's presence, the medication cart itself was locked and inaccessible to clients. Facility staff confirmed that the medication cart remains locked at all times, except during active medication administration. Staff also reported that the Administrator’s office is kept locked whenever the Administrator is not present, unless medications are being administered. Based on observations and interviews, the Department has insufficient evidence to support the allegation of “staff did not properly store medication”. Therefore, this allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

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

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

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20250311092937
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: 09/09/2025
NARRATIVE
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Report Continued from LIC 9099C...

It was also alleged that staff is not adequately trained. It was reported that facility staff are not adequately trained and unqualified to be administering medications to residents and safety drills are not being conducted quarterly. Per facility Program, in Policy Training: Medication Education, it states that “… each staff will receive thorough training in medication management and other pertinent medication information during their initial training period and subsequently in yearly required in-services and as needed”. Records reviewed including training records for facility staff demonstrated that staff are taking medication training along with other training specific or related to their job specification. Additionally, record review of facility’s emergency disaster plan revealed that emergency disaster drills are being conducted quarterly as per regulation. Furthermore, record review and interviews conducted indicate that emergency disaster drills are being conducted at least once a month. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff is not adequately trained”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was also alleged that staff does not provide scheduled activities for residents. It was reported that there is no curriculum scheduled for residents to follow. During a facility walkthrough, the LPA observed an Activity Calendar posted in the common area, listing at least three (3) different activities scheduled each day. Additionally, clients were observed actively participating in group activities at the time of the visit. Interviews with staff revealed that clients enjoy participating in activities when they are offered. Staff reported that clients particularly enjoy working on worksheets provided by one of the staff members. Furthermore, client interviews confirmed that activities are offered daily by the facility. Although participation is not mandatory, they are encouraged to join, and most express enjoyment in taking part. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff does not provide scheduled activities for residents”. Therefore, this allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

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

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

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20250311092937
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: 09/09/2025
NARRATIVE
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Report Continued from LIC 9099C...

It was further alleged that there is Insufficient staffing. It was reported that staff is rotated between facilities and there are not enough to cover all houses. During the course of the investigation, the LPA obtained and reviewed timecards and staff schedules for the month of February 2025 and conducted interviews with both staff and clients. At the time of the complaint allegation, there were at least two staff members scheduled for each shift in the AM, PM, and NOC. Timecards confirmed that, although staff schedules varied, there was sufficient staffing to cover unforeseen shortages. Further record review and interviews conducted revealed there are additional on-call staff, as well as the use of outside agency staffing when necessary. Staff interviews indicated that agency staffing had been utilized for some time prior to the facility becoming fully staffed. Staff also reported that there are consistently two staff members on duty at all times, along with one floater who is able to move freely throughout the facility to provide assistance where needed. Client interviews confirmed that at least two staff members are present at all times, and no concerns were expressed regarding staffing levels or living at the facility. Additionally, a review of Guardian records confirmed that all staff are fingerprint-cleared and associated with all on-site facilities, allowing them to work double shifts or assist at other facilities as needed. Based on the information obtained and reviewed during the course of the investigation, the Department has insufficient evidence to support the allegation of “insufficient staffing”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of the report issued.

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

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

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
03/11/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20250311092937

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:
09/09/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:McKian NielsenTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
Staff not keeping hallway free of obstruction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 03/17/2025 by LPAs M. Arroyo and V. Conway, and a subsequent visit was conducted on 07/09/2025 by LPA M. Arroyo. On today’s visit, the LPA met with Administrator, McKian Nielsen. Entrance interview conducted.

During the initial visit on 03/17/2025, the LPAs conducted a plant tour starting at 02:17 p.m., observed the centrally stored medications area and conducted a medications review starting at 02:32 p.m., conducted interviews with two staff at 02:25 and 02:40 p.m., and obtained copies of pertinent documents relevant to the investigation. On 07/09/2025, between 02:30 p.m. and 03:30 p.m., LPA Arroyo conducted interviews with two staff and four clients and obtained copies of pertinent documents relevant to the investigation.

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

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

DATE: 09/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20250311092937
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: 09/09/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff are not keeping hallway free of obstruction. It was reported that there are brooms and other objects in the hallways creating a hazard and concern for residents’ safety. During the facility walkthrough on 03/17/2025, the LPA observed several items obstructing the emergency passageway in the hallway. These items included but were not limited to, brooms, mops, mopping cart, dustpans, and a basket. Interviews conducted with staff revealed that they are currently working on clearing out a closet to use as storage for all cleaning supplies. Furthermore, emergency exit was obstructed during facility visit. Based on observations, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff are not keeping hallway free of obstruction” 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: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20250311092937
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: 09/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2025
Section Cited
CCR
80087(a)(c)
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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement was not met as evidenced by:
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The Administrator had hallway cleaned up during the inspection.

POC has been met.
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Based on observations, the Licensee did not comply with the section cited above as an emergency exit hallway was observed with cleaning supplies obstruction the exit, which posed 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: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7