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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609628
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:14:06 PM

Document Has Been Signed on 01/04/2024 02:14 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CORNERSTONE FACILITIES, LLCFACILITY NUMBER:
197609628
ADMINISTRATOR:JHOMER YUSONFACILITY TYPE:
735
ADDRESS:504 W AVE H13TELEPHONE:
(818) 687-3830
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: 4DATE:
01/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica Cruz SemickTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregiver. LPA stated the purpose of the visit was to conduct an annual inspection. The caregiver confirmed there are four clients. The facility is licensed for four clients. The House Manager arrived at 10:10 am.

LPA Spaeth and the caregiver toured the location at 10:10 am until 10:30 am.

Common Areas – LPA observed the living room contained comfortable seating and a television. The dining room area is furnished with a table.

Laundry Room – The laundry room contained washer and dryer.

Hallway Closets – The hallway closet was locked and contained laundry detergent, cleaning solutions, and resident hygiene items.

Kitchen – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food items. The medications are locked in a kitchen cabinet. The cleaning solutions and knives are locked underneath the kitchen sink.

Hot Water Temperature – LPA tested the water temperature at 10:30 am which was 115.0 degrees F.


Resident Bedrooms - There are four resident bedrooms which are furnished with a bed, linens, night stand, chest of drawers and a closet.

Bathroom – There are two bathrooms in the facility which contained hand soap, paper towels and a trash can.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CORNERSTONE FACILITIES, LLC
FACILITY NUMBER: 197609628
VISIT DATE: 01/04/2024
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Backyard - Comfortable outdoor seating is provided for the residents. The side gate leading from the backyard to the front yard was not locked.

Garage - LPA observed the garage was locked. An additional refrigerator is located in the garage and contained additional frozen food items. The first aid kit was located in the garage. Additional resident hygiene items were locked in the garage.

Smoke/Carbon Monoxide Detectors – The detectors were tested at 10:25 am and were operable.



LPA reviewed residents' records at 10:40 am until 11:15 am. LPA reviewed staff records at 11:15 am until 11:45 am. LPA observed the P&I at 11:45 am until 11:50 am. LPA reviewed resident medications at 11:50 am until 12:00 pm.

There are no deficiencies to report. The exit interview was conducted, and a copy of the signed report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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