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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850228
Report Date: 02/10/2022
Date Signed: 02/10/2022 04:45:43 PM

Document Has Been Signed on 02/10/2022 04:45 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A CORNERSTONE SAFE CAREFACILITY NUMBER:
565850228
ADMINISTRATOR:LUMBRES, SUSANFACILITY TYPE:
740
ADDRESS:3021 PAIGE AVENUETELEPHONE:
(818) 602-1350
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 0DATE:
02/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Susan LumbresTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a Pre-licensing visit at the facility. LPA met with Applicant Representative and Admiistrator Susan Lumbres.

At 11:00am LPA and administrator toured the physical plant area. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. LPA observed Fire extinguishers to be purchased in July 2021. Smoke detectors and Carbon Monoxide detectors appeared to function properly during time of visit. Facility is a single-story residence and consists of a total of four (4) bedrooms and two (2) bathrooms. Fire clearance was approved on 12/01/2021 for six (6) non-ambulatory residents, one of which may be bedridden. Fire extinguisher observed in the kitchen - purchased 11/2021 observed fully charged. During physical plant tour LPA observed the postings throughout the facility. Administrator will get the CDSS Complaint poster and post in the facility from either the main office or online.

Bedrooms: The resident bedrooms were properly furnished with a bed, night stand, chair, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: All bathrooms observed clean, properly supplied and had functional fixtures. LPAs observed all bathrooms to have grab bars and non-skid mats. The hot water was measured in each bathroom between 105 - 111 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Activities and games observed accessible for use. Kitchen: The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPAs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked cabinet in the kitchen. Medications are planned to be kept in the living room area in locked individual cabinets. Cleaning supplies and/or toxins will be kept in locked cabinet in the kitchen. Garage: Access from Kitchen area to the garage. Garage is set-up for office use and rest/break area for off duty staff. Washer and dryer is also in the garage. (continue to LIC809c)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A CORNERSTONE SAFE CARE
FACILITY NUMBER: 565850228
VISIT DATE: 02/10/2022
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Outdoor Area: There was a shaded area with sufficient room for activities. There is a spa in the backyard which was locked and no water inside according to administrator. There is one fenced gate on the side of the house. This fence/gate did not have a spring to self-latch. Administrator agreed to have a spring installed. Passageways for emergency exit use observed clear. PPE supply appeared to be sufficient at this time. Comp III was completed in conjunction with the visit.

The following needs to be completed/proof submitted prior to the facility being licensed:

1. Installed a self-latching mechanism for the fence/gate on the side of the house. Submit photo to LPA once installed.

An exit interview was conducted with Administrator, and a hard copy was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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