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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609628
Report Date: 12/10/2024
Date Signed: 12/10/2024 01:17:59 PM

Document Has Been Signed on 12/10/2024 01:17 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CORNERSTONE FACILITIES, LLCFACILITY NUMBER:
197609628
ADMINISTRATOR/
DIRECTOR:		JHOMER YUSONFACILITY TYPE:
735
ADDRESS:504 W AVE H13TELEPHONE:
(818) 687-3830
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: 4DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:21 AM
MET WITH:Jessica Cruz- House ManagerTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 12/10/2024 at approximately 10:15 AM, Licensing Program (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by House-Manager Jessica Cruz. LPA stated the reason for the visit. House-Manager then called Administrator Jhomer Yuson who delegated House-Manager Cruz to oversee today’s visit and sign any documentation needed Shortly after Administration Yuson arrived..

LPA asked for census, staff, and client files. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with four (4) bedrooms and two (2) bathrooms currently occupying four (4) residents. The facility is fire cleared for four (4) ambulatory clients.

Required postings such as Emergency Disaster Plan, Yes Poster, and Rights of Individuals with Developmental Disabilities were located at the main entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

Both living room and dining room observed to be neat, clean, and organized. Both observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 68°F. Fire extinguisher located near kitchen dated 5/13/24. Staff reception area located in living room leading towards the backyard.

The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Cleaning solutions and knives/sharps are kept locked under kitchen. Stove observed to be working and in proper condition. Working telephone located in kitchen. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CORNERSTONE FACILITIES, LLC
FACILITY NUMBER: 197609628
VISIT DATE: 12/10/2024
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The backyard of the facility is equipped with a designated shaded area with outdoor furniture for clients. There is no body of water in this facility.

The Garage can be accessed from the inside of the facility. The garage is equipped with an extra refrigerator/freezer and fully stocked with food. Employee and staff files kept locked in storage inaccessible to clients. Extra cleaning solutions and toxins kept locked in storage inaccessible to clients.

Smoke detectors and carbon monoxide observed to be working properly and were tested. Fire/Emergency Evacuation Drill conducted 11/26/24.

The laundry room located in hallway near main entrance. Laundry room can be accessed from the inside of the facility. Laundry detergents, cleaning agents, and other toxins are stored in a locked cabinet in hallway area inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Clients have sufficient personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at 110.1°F. Towels and washcloths are not shared. Sufficient availability of clean lien and extra PPE stored in hallway cabinet.

Medications: LPA observed medication in the kitchen stored in a locked cabinet and inaccessible to clients. Medication usage recorded and stored properly. LPA along with House-Manager Cruz conducted a review of the medication to ensure compliance. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual.

Client records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated.

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was provided to facility representative, Jessica Cruz.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
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