565801331-12-17-2024-29-AS-MARO-DC2VK2-20241217152938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801331
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:29:52 PM

Document Has Been Signed on 12/17/2024 03:29 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/ DIRECTOR:	JESUS CARDENAS		FACILITY TYPE:	735
ADDRESS:	1758 SOUTH LEWIS ROAD		TELEPHONE:	(805) 383-3669
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY: 15		CENSUS: 15	DATE:	12/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Isabelle Blecher		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Martha Arroyo conducted a required annual inspection today at 9:30AM. Upon arrival there were two (2) staff and fifteen (15) residents present. The LPA met with staff and the reason for the visit was explained. The Residential Program Managers, Ash Earle and Isabelle Blecher arrived shortly after. Entrance interview conducted. At 10:40AM, the LPA along with the Residential Program Manager, 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: KITCHEN: The facility is equipped with two separate kitchens. Both kitchens were equipped with fixtures and appliances that appeared clean and functional. The first kitchen observed is for resident use. The refrigerator was observed with resident’s snacks and leftovers. The second kitchen is for staff use and daily cooking. There was an adequate supply of perishable and nonperishable foods. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. Knives and sharps were observed in a locked cabinet at the time of the visit. BEDROOMS: There were 15 bedrooms designated for resident use. Resident bedrooms were observed to be designated for single occupancy and were properly furnished, including adequate supplies of bedding and linen, with sufficient lighting. Additional clean linens were observed for resident use. Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

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: 12/17/2024

NARRATIVE

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Report Continued from LIC 809...

BATHROOMS: Each resident bedroom includes an individual half bathroom. All bathrooms observed were properly supplied with paper products and soap. Bathroom fixtures were observed to be functional at the time of the visit. The LPA observed two (2) small showers and two (2) large showers. Starting at 10:44AM, the hot water temperature was measured in various bathrooms throughout the facility, and they measured within the necessary range as they measured between 115.8 degrees Fahrenheit and 12o degrees Fahrenheit.

COMMON AREAS: Common areas include two (2) dining areas and two (2) living rooms. All common areas were adequately furnished for resident use. There is also a laundry room, which residents utilize. Staff provide cleaning detergent upon request. All hazardous cleaning chemicals were observed to be stored, locked, and inaccessible to residents at the time of the visit. Carbon monoxide detectors were tested and operational at the time of the visit. Several fire extinguishers were observed throughout the facility and were fully charged and last serviced on 11/06/2024.

SURROUNDING GROUNDS: There are several shaded areas with adequate furniture for resident use.
MEDICATIONS: At approximately 11:50AM a medications review of five (5) randomly selected residents was conducted. Medication are stored inside the staff office in a locked cabinet. All medications reviewed were stored and documented per regulation.

RECORD REVIEW: LPA reviewed Resident Records at 10:10AM and Personnel Records at 12:45PM.

Seven (7) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. Record review revealed that one (1) out of seven (7) resident files reviewed was missing a physician’s report. Staff stated they will be obtaining a new physician's report for resident.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

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: 12/17/2024

NARRATIVE

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Report Continued from LIC 809C...

Five (5) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff files were complete.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: 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. The last emergency disaster drill was conducted on 11/12/2024.

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. Today’s reports and appeal rights were reviewed and issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/17/2024 03:29 PM - It Cannot Be Edited

Created By: Martha Arroyo On 12/17/2024 at 02:46 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STONEHENGE	FACILITY NUMBER: 565801331
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(b)

Client Medical Assessments

(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as one (1) out of seven (7) resident files reviewed was missing the physician's report, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2024
	Plan of Correction
1 2 3 4	Licensee will obtain phycian's report for resident and submit to CCL no later than POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Desaree Perera

LICENSING EVALUATOR NAME:

Martha Arroyo

LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

LIC809 (FAS) - (06/04)

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