079200820-10-23-2025-15-AS-BFOG-DNCUB4-20251112142542

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200820
Report Date: 10/23/2025
Date Signed: 10/23/2025 04:19:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2024 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240202150258

FACILITY NAME:	STONEHEDGE GUEST HOME		FACILITY NUMBER:	079200820
ADMINISTRATOR:	ANDREW GARDNER		FACILITY TYPE:	740
ADDRESS:	1415 STONEHEDGE DR		TELEPHONE:	(925) 957-6813
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 6	DATE:	10/23/2025
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Josefina Gardner, Licensee		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained a fracture due to lack of care from staff
Staff did not seek medical care for resident in a timely manner

INVESTIGATION FINDINGS:

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On 10/23/2025 at 12:45 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Licensee, Josefina "Penny" Gardner, to deliver the findings of above allegations. LPA explained the purpose of the visit with Licensee.

During the investigation, the Department obtained and reviewed the following documents from the facility: personnel record dated 02/05/2024, residents’ roster dated 10/01/2023, admission agreement dated 09/19/2023, physicians report 09/18/2023, needs & services plans, Physicians orders dated 09/18/2023, narrative charting, medication worksheets 09/18/2023.

LIC9099-C Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240202150258

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STONEHEDGE GUEST HOME	FACILITY NUMBER: 079200820
	VISIT DATE: 10/23/2025

NARRATIVE

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LIC9099-C (Page 2)

Allegation: Resident sustained a fracture due to lack of care from staff
Investigation Finding: Unsubstantiated

On 12/09/2023 at approximately 0700 AM staff (S1) heard resident (R1) shouting for help, and S1 came to R1’s aid. S1 found R1 sitting on the floor, complaining of back pain while holding onto his hip. S1 did not observe any visible injuries on R1. S1 offered to call 911, but R1 declined and requested assistance to stand. S1 helped R1 back to bed and resumed his duties.

Allegation: Staff did not seek medical care for resident in a timely manner
Investigation Finding: Unsubstantiated

Review of R1’s medical documents, from Kaiser Permanente at Walnut Creek revealed on 12/09/23 at approximately 0330 a.m., R1 sustained an unwitnessed fall. During the night shift, S1 reported the fall to the oncoming day shift caregiver, S2, at approximately 0700 a.m. At approximately 0900 a.m., S2 informed the in-house Registered Nurse (S3) of the incident.

S3 provided instructions to S2 over the phone to assess R1. S2 documented no visible marks, bruises, skin tears, or discoloration, but noted that R1 moaned in pain when moved. S3 did not instruct S2 to call 911, nor did S3 advise any additional assessment. The direction provided was to administer pain medication, monitor R1 for one hour, and, if R1’s family did not respond within two hours, arrange transport to the hospital.

LIC9099-C Continued...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240202150258

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: STONEHEDGE GUEST HOME	FACILITY NUMBER: 079200820
	VISIT DATE: 10/23/2025

NARRATIVE

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LIC9099-C (Page 3)

At approximately 0725 a.m., S2 attempted to contact R1’s family. The call went to voicemail, and a message was left requesting a return call. At approximately 1100 a.m., R1’s daughter arrived at the facility. R1 was transported to Kaiser Walnut Creek Emergency Department at approximately 1200 p.m. Documentation shows that at approximately 1400 p.m., staff were notified that R1 had sustained a hip fracture.

Based on records review, interviews conducted, and observations made, the Department has investigated the above allegations of “Resident sustained a fracture due to lack of care from staff” and “Staff did not seek medical care for resident in a timely manner” and found it to be unsubstantiated. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations of resident sustained a fracture due to lack of care from staff and staff did not seek medical care for resident in a timely manner is unsubstantiated.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC9099 (FAS) - (06/04)

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