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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609628
Report Date: 10/27/2021
Date Signed: 10/27/2021 12:49:16 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210601081832
FACILITY NAME:CORNERSTONE FACILITIES, LLCFACILITY NUMBER:
197609628
ADMINISTRATOR:ANDERSON MUNOZFACILITY TYPE:
735
ADDRESS:504 W AVE H13TELEPHONE:
(818) 687-3830
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:4CENSUS: 4DATE:
10/27/2021
UNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Latasha MoodyTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident got into an altercation with another resident due to lack of supervision
Staff recorded resident without resident consent
Staff speak inappropriately to resident
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced visit at 10:13 am and was greeted by Caregiver, Latasha Moody. Upon arrival, LPA observed the COVID sign on the front door. LPA's temperature was taken and was asked the COVID questions. LPA signed in and caregiver confirmed there are four residents in the facility. LPA Spaeth explained the purpose of the visit is to investigate a complaint. It was alleged that resident got into and altercation with another resident due to lack of supervision, staff recorded resident without resident consent, and staff spoke inappropriately to resident.

On October 25, 2021, LPA interviewed caregivers J. Munoz and M. Buenavilla who both confirmed were present at the facility during the altercation. Both caregivers confirmed were trying to redirect resident R1 and R2 but residents did not comply to the request. Caregivers then called the police. J. Munoz spoke to LPA Avetisyan on June 4, 2021 and confirmed R1 was taken to jail due to assaulting R2. Caregiver J. Munoz confirmed there were three staff members present during the incident. Therefore the allegation, resident got into an altercation with another resident due to lack of supervision is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20210601081832
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CORNERSTONE FACILITIES, LLC
FACILITY NUMBER: 197609628
VISIT DATE: 10/27/2021
NARRATIVE
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In regard to the allegation, staff recorded resident without resident consent. LPA Spaeth spoke to R1 on June 22, 2021 and asked for name of resident who recorded incident on phone. R1 stated did not remember if this happened. LPA Spaeth spoke to Caregivers J. Munoz and M. Buenavilla on October 25, 2021 via phone call and asked if a caregiver recorded altercation on phone. Both caregivers stated no. Therefore, the allegation is unsubstantiated at this time.

LPA Spaeth asked Caregiver M. Buenavilla and J. Munoz on October 25, 2021 if spoke to R1 in an inappropriate manner. Both caregivers stated no. LPA also asked if caregivers witnessed other caregivers speaking to R1 in an inappropriate manner. Both caregivers stated no. LPA Spaeth spoke to R1 on June 22, 2021 and asked name of staff who spoke to R1 in an inappropriate manner. R1 stated did not remember making that statement. Therefore the allegation, staff speak inappropriately to resident is unsubstantiated.

Exit interview was conducted and appeal rights discussed. A copy of the report was given to Caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2