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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880669
Report Date: 02/12/2025
Date Signed: 02/12/2025 03:51:25 PM

Document Has Been Signed on 02/12/2025 03:51 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:CORNERSTONE SENIOR HOME CAREFACILITY NUMBER:
331880669
ADMINISTRATOR/
DIRECTOR:		EVELYN CABALESFACILITY TYPE:
740
ADDRESS:26798 RODEO CTTELEPHONE:
(951) 223-3212
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 5CENSUS: 3DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Evelyn Cabales, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:14 PM
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On 02/12/2025 at 11:45 AM, Licensing Program Analysts (LPAs) Melody Brown and Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Brown and Serrano met with a Administrator Evelyn Cabales and was granted entry to the facility. At the time of the visit there were two (_2_) staff present, and three (_3_) residents present.LPAs Brown and Serrano explained the purpose of the visit to Administrator.

The facility is a Five () bedroom, three (3) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of five (5) residents of which five (5) can be non-ambulatory. The facility has five (5) Hospice Waiver. The current census is three (3) residents. LPAs Brown and Serrano was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPAs Brown and Serrano observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees Fahrenheit. LPAs Brown and Serrano inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPAs Brown and Serrano observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. LPA observed that the loft on the second floor was converted into a bedroom. Deficiency will be issued.

Also, LPAs Brown and Serrano observed Resident #1 (R1), Resident #2 (R2), Resident #3 (R3 have half bed rails. Administrator Cabales reported to LPAs Brown and Serrano that R1, R2, R3 does not have written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued.

***Continuation in LIC809C ***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CORNERSTONE SENIOR HOME CARE
FACILITY NUMBER: 331880669
VISIT DATE: 02/12/2025
NARRATIVE
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Moreover, during the tour of the facility, LPAs Brown and Serrano observed sufficient furniture and lighting throughout the facility. LPA Serrano measured and observed the water temperature in the bathroom to be at 111.3 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area.

Furthermore, during the tour of the facility, LPAs Brown and Serrano observed the sharps and chemicals locked in kitchen cabinets, inaccessible to residents in care. There is a designated storage space for resident/staff files. The resident’s medications is locked in the medication drawer inaccessible to resident in care.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. LPA observed that the facility do not have the 72 hour emergency food and supplies ready to go in case of a disaster. Deficiency will be issued.

Care & Supervision: The facility has an administrator present during the visit. LPAs Brown and Serrano observed sufficient number of staff to provide care and supervision to the residents in care. No dementia residents observed at the facility.

Record Review: LPAs reviewed resident #1 (R1) resident#3 (R3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed that the admission agreement for R1 was not signed and dated by the licensee/designee and R3 pre-placement appraisal was not signed and dated by the representative. LPAs observed during medication audit that R3 that one (1) medication was not given for 2 days. Deficiency will be issued.



***Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: CORNERSTONE SENIOR HOME CARE
FACILITY NUMBER: 331880669
VISIT DATE: 02/12/2025
NARRATIVE
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LPAs reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPAs found that Staff #2 (S2) does not have an updated first aid certification and health screening. Deficiency will be issued.

An exit interview was conducted where this report LIC809, LIC809C, LIC809D and Appeal Rights were discussed and provided to Administrator Evelyn Cabales.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/12/2025 03:51 PM - It Cannot Be Edited


Created By: Eldin Serrano On 02/12/2025 at 02:39 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CORNERSTONE SENIOR HOME CARE
FACILITY NUMBER: 331880669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring S2 have the required First aid/CPR certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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2
3
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Licensee provided proof of S2 registration to complete the required First aid/CPR certification at the time of visit. Plan of correction(POC) cleared..
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that staff #2 (S2) have the required health screening report. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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LIcensee stated that they will make the doctors appointment to complete the required health screeening on 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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 02/12/2025 03:51 PM - It Cannot Be Edited


Created By: Eldin Serrano On 02/12/2025 at 02:39 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CORNERSTONE SENIOR HOME CARE
FACILITY NUMBER: 331880669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above that Staff #2 (S2) have the required tuberculosis (TB) test with result maintained in their facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Licensee stated that they will submit the required tuberculosis (TB) test with result by the plan of correction (POC) due date.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above that resident # (R3) one (1) medication was not given for two (2) days as evidence of medication administration record (MAR) was not updated which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Licensee stated that they will submit an In-Service training that is signed and dated by the staff 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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 02/12/2025 03:51 PM - It Cannot Be Edited


Created By: Eldin Serrano On 02/12/2025 at 02:39 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CORNERSTONE SENIOR HOME CARE
FACILITY NUMBER: 331880669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

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 by not ensuring that the proper building permit and notification to CCLD was submitted prior to converting the loft to a bedroom which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Licensee stated to obtain the required building permit/tear down the converted loft and submit to LPA Serrano by the plan of correction (POC) due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview,record review, the licensee did not comply with the section cited above by not ensuring that resident #(R3) have a signed and dated pre-placement appraisal.which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Licensee signed and dated the R3 pre placement appraisal at the time of visit. POC cleared.
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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 02/12/2025 03:51 PM - It Cannot Be Edited


Created By: Eldin Serrano On 02/12/2025 at 02:39 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CORNERSTONE SENIOR HOME CARE
FACILITY NUMBER: 331880669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observationinterview record review, the licensee did not comply with the section cited above by not ensuring that resident #1 (R1) does not have the required admission agreement signed and dated by licensee or designee which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2025
Plan of Correction
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Licensee signed the admission agreement at the time of visit. Plan of correction cleared.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation,interviewrecord review, the licensee did not comply with the section cited above by not ensuring that the facility have the required 72 hour emergency food and supplies. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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2
3
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Licensee will submit proof of purchase of food and supplies for the required 72 hours emergency food and supply on 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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 02/12/2025 03:51 PM - It Cannot Be Edited


Created By: Eldin Serrano On 02/12/2025 at 02:58 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CORNERSTONE SENIOR HOME CARE
FACILITY NUMBER: 331880669

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Based on the indivduals preadmission appraisal and subsequent cahnges to that appraisal, the facility shall provide assistance and care...(5)Under no circumtances shall postural supports include...(A) A bed rail that extends from head half the lenght of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that resident #1, #2, #3 (R! R2 R3) have written orders from their physician indicating the neded for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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2
3
4
LIcensee stated to obtain R1 R2 R3 written order form their physician indicating the need for half bed rail for mobility and submit a copy to LPA Serrano by plan of correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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