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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920115
Report Date: 10/16/2024
Date Signed: 10/16/2024 12:35:01 PM

Document Has Been Signed on 10/16/2024 12:35 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STONERIDGE CARE HOMEFACILITY NUMBER:
345920115
ADMINISTRATOR/
DIRECTOR:		MUBEEZI, VIOLETFACILITY TYPE:
740
ADDRESS:7551 STONERIDGE WAYTELEPHONE:
(916) 745-4659
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 6CENSUS: 6DATE:
10/16/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Violet MubeeziTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On 10/16/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Post Licensing inspection. LPA met with Staff and explained the purpose of the visit. Staff who then contacted Administrator Violet Mubeezi, who then arrived to the facility shortly.

LPA and staff conducted a tour of the interior and exterior of the facility. Areas toured include six (6) bedrooms, three (3) bathrooms, kitchen, common areas and the backyard. While on tour LPA observed two (2) residents residing in a room that is not cleared by the fire department for residents. LPA observed medication cabinet to be unlocked due to the lock being broken.

LPA conducted a file review of resident and staff files

CARE inspection tool completed and deficiencies was observed. Please see LIC 809-D. Today's visit, civil penalties assessed.

LPA requested a copy of facility's liability insurance, LIC 500 and LIC 308 by 10/18/24

Exit interview conducted and a copy of the report and appeal rights was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/16/2024 12:35 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 10/16/2024 at 11:59 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STONERIDGE CARE HOME
FACILITY NUMBER: 345920115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in residents medication was not in a safe locked place which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee immediately moved medication to locked cabinet and ordered a new medication cabinet that will be a the facility later today. Licensee to also send LPA a statement of understanding of this regulation.
Type A
Section Cited
CCR
87203
87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation and record review , the licensee did not comply with the section cited above in 2 out of 6 residents were residing in a room not fire cleared which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee to move both residents out of the bedroom and into the fire clearance approved rooms. Once completed Licensee will send LPA proof of residents no longer residing unapproved room. Licensee will also send LPA statement of understanding of this regulation by POC due date
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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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