Stonewall Gardens Assisted Living

Allegation investigated: Staff physically assaulted resident

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Clayshanisha Henson, Resident Service Director. The Department investigation involved interviews with staff and residents and reviews of records. On 11-06-2025, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff physically assaulted resident. Information received indicated that Staff #1 (S1) struck Resident #1 (R1) in the face while providing care during night shift. As a result, R1 sustained bruising and swelling on the face. Continued on LIC9099-C.... Substantiatedthe state’s words, verbatim · CDSS document, Mar 12, 2026 · control 18-AS-20251106134235

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Unqualified staff providing medical care. Staff tested positive for COVID.

On November 20, 2025, the Department of Social Services staff conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. The Department was met by Nisha Henson and the purpose of the visit was explained. Investigation consisted of the following: On October 28, 2021, the Department conducted an unannounced initial visit to the facility to investigate the complaint allegations mentioned above. During the visit, it was determined that the complaint required further investigation. At time of visit, the Department interviewed 5 staff (S1-S5) and 3 residents (R1-R3). The Department obtained the following pertinent documents: Email correspondence (dated: 10/25/21 at 2:44pm), Weekly Care Schedule (dated:10/4/21), Staff training certificates (dated 4/1/21), Staff Roster (no date), Kitchen schedule (no date). On November 20, 2025, the Department requested and obtain the following documents: Staff roster (dated: 11/2025), Resident Rthe state’s words, verbatim · CDSS document, Nov 20, 2025 · control 18-AS-20211025095214

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff not supervising resident resulting in multiple falls Resident’s money was stolen

Licensing Program Analyst, (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA met with Marketing and Resident Enrichment Director, Brian Trout, where LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of observation, interviews with staff members and residents, and records review. On 12/07/2020, Community Care Licensing received a complaint alleging that Staff did not supervise resident resulting in multiple falls and Resident’s money was stolen. It was reported that R1 was being hospitalized due to multiple falls and that staff members were not supervising the resident. Information obtained from an interview with Administrator, Chad Boeddeker stated R1 would sustain bruises occasionally due to being a fall risk. Administrator reported R1 would not request staff assistance when ambulating. Information obtained from interviews with additionalthe state’s words, verbatim · CDSS document, May 17, 2024 · control 18-AS-20201207165056

Allegation investigated: Resident is being illegally evicted.

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to deliver findings on complaint investigation regarding the allegation listed above. LPA spoke to the Executive Director, Lauren Vincent over the phone and met with Kitchen Chef, Brian Lebeuf and explained the purpose of the visit and the elements of the allegation. LPA Banrasavong conducted the investigation which consisted of observation, interviews with staff members and resident, and record reviews. On 02/28/2024, Community Care Licensing received a complaint stating that the facility is illegally evicting Resident (R1). It was reported that the facility did not follow the 30-day eviction guidelines, did not properly serve the resident, and did not give the resident proper resources to find alternative housing. During the LPA’s initial visit, LPA was able to speak to R1 and confirmed that he was properly served with the 30-day notice on the date that the facility submitted the notice tothe state’s words, verbatim · CDSS document, Mar 27, 2024 · control 18-AS-20240228155354

Allegation investigated: Staff did not ensure resident attended his medical appointments Staff did not meet resident's dietary needs Staff mismanaged resident's medication Staff falsified residents' records Administrator is not at the facility a sufficient amount of time

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to deliver findings for a complaint investigation regarding the allegations listed above. LPA met with Executive Director, Lauren Vincent over the phone and met with Kitchen Chef, Lebeuf and explained the purpose of the visit and the elements of the investigation. LPA Banrasavong conducted the investigation, which consisted of observation, interviews with staff members, residents, and record reviews. LPA was unable to interview additional witnesses in order to obtain pertinent information. On 02/12/2024, Community Care Licensing received a complaint alleging that the facility is not ensuring resident is attending his medical appointments. The LPA attempted to reach out to the Reporting Party (RP) on three separate occasions but was not able to make contact with the RP. LPA interviewed the resident (R1) that was named in the complaint. During the interview, the resident indicted that they hadthe state’s words, verbatim · CDSS document, Mar 27, 2024 · control 18-AS-20240212161807

Allegation investigated: Staff are not transporting residents to medical appointments. Administrator is not on the premises for a sufficient number of hours. Facility is not following residents dietary plan. Facility does not have a nurse available to assist residents in care.

Licensing Program Analyst (LPA), Kathleen Banrasavong made an unannounced visit to the facility to deliver findings for a complaint investigation regarding the allegations listed above. LPA spoke to the Executive Director, Lauren Vincent over the phone and met with Kitchen Chef, Brian Lebuef and explained the purpose of the visit and the elements of the investigation. LPA Banrasavong conducted the investigation, which consisted of observation, interviews with staff members and residents, and record reviews. LPA was unable to interview additional witnesses in order to obtain pertinent information. On 02/12/2024, Community Care Licensing received a complaint alleging that staff are not transporting residents to medical appointments, Administrator is not on the premises for a sufficient number of hours, facility is not following residents dietary plan, and facility does not have a nurse available to assist residents in care. In regards to the allegations that staff are not transporting rethe state’s words, verbatim · CDSS document, Mar 27, 2024 · control 18-AS-20240212154137

Allegation investigated: Resident sustained unexplained bruising while in care. Staff did not safeguard resident's personal property.

Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to conclude the investigation into the above allegations. The LPA met with Interim Administrator, Lauren Kabakoff, and informed her of the purpose for the visit. A report was received by the Department alleging Resident One (R1) was observed with unexplained bruising to their neck on or around March 15, 2021. Administrator Chad Boeddeker was interviewed and reported R1 was observed with bruising; however, he stated R1 returned to the facility from a hospitalization with the injuries. He reported R1 would sustain bruises occasionally due to being a fall risk. He reported R1 would not request staff assistance when ambulating. Resident records were obtained on 03/23/2021. R1's Physician's Report (California) was reviewed; the document revealed the resident had no motor impairment or paralysis, was not confused or disoriented, and had no history of skin conditions or breakdown. An interviewthe state’s words, verbatim · CDSS document, Jan 30, 2024 · control 18-AS-20210315130523

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.