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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803484
Report Date: 01/15/2025
Date Signed: 01/15/2025 05:43:33 PM

Document Has Been Signed on 01/15/2025 05:43 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CORNERSTONE ASSISTED LIVINGFACILITY NUMBER:
486803484
ADMINISTRATOR/
DIRECTOR:		SHELLEY REYESFACILITY TYPE:
740
ADDRESS:40 ORANGE TREE CIRCLETELEPHONE:
(707) 999-5029
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 130CENSUS: 92DATE:
01/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Shelley Reyes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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At approximately 11:20 AM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a required 1-year annual inspection. Administrator, Shelley Reyes was contacted via telephone and arrived at approximately 12:00pm. Facility is a Residential Care Facility for the Elderly (RCFE) with ninety-two (92) residents in care. Facility has a hospice waiver for twelve (12), a bedridden waiver for thirty (30), and is approved for all non-ambulatory residents.

At approximately 12:45 PM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is two stories, was a comfortable temperature, and passageways were free from obstructions. LPAs observed evacuation chairs at each stairwell. Six (6) residents' apartments were inspected and water temperatures in Residents' bathrooms and communal bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of hygiene products, clean linens, paper products, and incontinent care briefs available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. The call system was tested in five (5) resident's rooms and Caregiver response time was between two (2) and four (4) minutes. Storage rooms containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Facility kitchen and walk-in refrigerator and freezer were inspected and all food is being properly labeled and stored. Additionally, LPAs observed a menu with a variety of options as well as a communication board for staff to communicate residents' dietary restrictions. Medications were centrally stored and locked. There are covered seating areas in the multiple outdoor courtyard spaces throughout the facility for activities. Facility has internet available to residents and has a library with two community desktop computers available to residents in care. Residents were observed engaged in Bingo and there was an activities calendar posted with a variety of engaging events and outings planned daily. There are activity/game rooms on both the first and second levels.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CORNERSTONE ASSISTED LIVING
FACILITY NUMBER: 486803484
VISIT DATE: 01/15/2025
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Continued from LIC809...

A small movie theater was observed on the 2nd level with a large selection of movies/DVDs for viewing. There is a salon available on site.

Facility's fire extinguishers were observed charged and were last serviced 12/2024. Facility's fire system is hardwired and was serviced in 1/2025. Facility conducts quarterly disaster drills with the most recent drill conducted 11/2024. LPAs observed facility's infection control plan and emergency disaster plan which was last updated 8/2024. LPAs observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness.

At approximately 2:00 PM, LPAs reviewed ten (10) staff files and ten (10) resident files. Ten (10) of ten (10) staff files reviewed have all of the required paperwork, proof of current First Aid and CPR training, and proof of all required training hours. Ten (10) of ten (10) resident files reviewed have all the required paperwork. Administrator and residents' families coordinates medical and dental visits for the residents and transportation to and from their appointments. Additionally, facility has a podiatrist who visits once per month.

At approximately 3:30 PM, LPAs reviewed medications and medication records which are maintained and stored in compliance with regulation. However, LPAs observed centrally stored medication records which do not accurately reflect the prescription labels for each respective medication, (see LIC809D). Facility does not manage P&I for residents.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 Personnel Report (updated)


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Administrator.

Exit interview conducted with Administrator whose signature on form confirms receipt of documents.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2025 05:43 PM - It Cannot Be Edited


Created By: Julie Florio On 01/15/2025 at 05:24 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CORNERSTONE ASSISTED LIVING
FACILITY NUMBER: 486803484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

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 ensuring that residents' centrally stored medication records are maintained in compliance with regulation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
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Licensee to submit proof of medication training completed by all facility medication technicians addressing regulatory compliant record keeping of the centrally stored medication records which accurately reflect the prescription labels on each medication to CCL by POC due date 2/17/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2025


LIC809 (FAS) - (06/04)
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