565801331-12-8-2023-29-AS-KDUK-CYC3YS-20231208174026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801331
Report Date: 12/08/2023
Date Signed: 12/08/2023 05:40:32 PM

Document Has Been Signed on 12/08/2023 05:40 PM - 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:	STONEHENGE		FACILITY NUMBER:	565801331
ADMINISTRATOR:	JESUS CARDENAS		FACILITY TYPE:	735
ADDRESS:	1758 SOUTH LEWIS ROAD		TELEPHONE:	(805) 383-3669
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY: 15		CENSUS: 14	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:41 PM
MET WITH:	Ayana Churn, Program Director		TIME COMPLETED:	05:45 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:41PM. LPA met with Program Director Ayana Churn. Entrance interview conducted.

Beginning at 12:58PM, the LPA, along with facility staff Morgan Sutono toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Smoke detectors and sprinkler system are regularly tested and no concerns identified. Carbon Monoxide detector was tested at 04:03PM and was functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 11/09/2023.

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 and non-perishable food as well as emergency water.

BEDROOMS: There are 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.

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: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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: 12/08/2023

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

RECORD REVIEW: Staff and client records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, client physician's report, needs and service appraisal, and personal rights. All 5 (five) client files and 5 (five) staff files reviewed were complete and contained all required documents.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 09/23/2023.

MEDICATION REVIEW: Medications for 2 (two) clients were observed. Both 2 (two) of 2 (two) clients' medications were observed to be maintained and administered in compliance with regulation.

INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 2 (two) clients.

No deficiencies cited. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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