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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850228
Report Date: 02/08/2023
Date Signed: 02/08/2023 03:40:25 PM

Document Has Been Signed on 02/08/2023 03:40 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: 3DATE:
02/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Susan LumbresTIME COMPLETED:
03:45 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 Administrator Susan Lumbres.

At 2pm LPA and administrator toured the physical plant area to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

Facility is a single-story residence and consists of a total of four (4) bedrooms and two (2) bathrooms. Fire extinguisher observed full charged in the kitchen; Smoke detectors and Carbon Monoxide detectors appeared to function properly during time of visit.


Today's annual has an emphasis on infection control practices and procedures.
During physical plant tour LPA observed the required postings throughout the facility. The facility has a sufficient supply of perishable and non-perishable food. Sufficient disinfecting/cleaning supplies observed (locked). The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are two bathrooms. Bathrooms had liquid soap, paper towels, and signs regarding proper hand washing. Backyard observed clear of any hazardous items. Passageways observed clear/no obstruction. INFECTION CONTROL: There is one (1) entry into the facility. Upon entry, the facility has a central entry point for symptom screening. Personal Protective Equipment (PPE) supply maintained. Ms. Lumbres stated she is able to order additional supplies with no issue.
The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

No deficiency observed during todays visit.
Exit interview held with staff. Copy of the report provided to Licensee/Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2023
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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