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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801331
Report Date: 12/13/2022
Date Signed: 12/14/2022 08:35:15 AM

Document Has Been Signed on 12/14/2022 08:35 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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:
12/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jesus CardenasTIME COMPLETED:
03:38 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a required annual visit and inspection. This visit had a specific emphasis on infection control practices and procedures. LPA met with Jesus Cardenas, Program Manager. Entrance interview conducted.

A tour of the physical plant was initiated at 3:00PM. LPA was accompanied by the Program Manager.

Fire extinguishers observed were fully charged and tagged as serviced in 2022.

KITCHEN: The facility is equipped with two separate kitchens designated as Kitchen A and Kitchen B. Both kitchens were equipped with fixtures and appliances that appeared clean and functional. There was an adequate supply of perishable food to accommodate 15 clients for two days and nonperishable food to accommodate 15 clients for one week.

BEDROOMS: There were 15 bedrooms designated for client use. All bedrooms were furnished for single occupancy and were properly furnished and had adequate supplies of bedding and linen. No visible hazards were observed.

BATHROOMS: Each of the 15 bedrooms included an individual half bathroom equipped with a sink and commode. All bathrooms were properly supplied with paper products and personal hygiene items and fixtures were observed to be functional at the time of the visit. There was one bathroom located in the main entrance designated for staff use only. There were four shower rooms, two at each end of the facility designated for client use, which appeared functional at the time of the visit. Water temperature was taken and measured within the required range of 105 to 120 degrees Fahrenheit.

Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: STONEHENGE
FACILITY NUMBER: 565801331
VISIT DATE: 12/13/2022
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COMMON AREAS: These included two dining areas, one adjacent to each Kitchen and designated as A and B. There were two Living Rooms, one adjacent to each dining area also designated as A and B. All common areas were adequately furnished to accommodate a maximum capacity of 15 clients.

SURROUNDING GROUNDS: The surrounding grounds included Parking Lots, Walkways, and Lawns. There were various shady areas available for clients. There were no immediate or imminent hazards observed.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Program Manager regarding the facility’s infection control practices. There are 2 entries into the facility. Upon entry, the facility has a central entry point for symptom screening. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room and shower room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

At the conclusion of the visit, Program Manager Jesus Cardenas met with LPA; exit interview conducted. A copy of report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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