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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609628
Report Date: 09/09/2022
Date Signed: 09/09/2022 05:24:25 PM

Document Has Been Signed on 09/09/2022 05:24 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., STE. 250
WOODLAND HILLS, CA 91364
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:
09/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jessica CruzTIME COMPLETED:
05:30 PM
NARRATIVE
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LPA Spaeth arrived to the facility to complete an unannounced visit regarding an incident report received by CCL. LPA Spaeth knocked at the door but there were no staff present at the facility. At 3:40 pm, LPA spoke to Administrator via phone and was informed staff would be returning to the facility. At 3:45 pm, LPA observed an individual coming from the backyard to the front yard. LPA asked if individual was a resident and resident stated yes. Resident stated was waiting for staff to return to the facility. Resident then went to the backyard to wait for staff. LPA called Administrator and stated resident was at the facility but there were no staff members present at the facility. Administrator then stated a staff member was on the way to the facility.

Caregiver arrived at 3:55 pm and unlocked the front door. Upon entering the facility, LPA stated the purpose of the visit. LPA observed the resident had entered the house from the backyard. Caregiver stated unlocked the back door for resident to enter.

LPA Spaeth conducted a facility tour at 4:00 pm and was escorted by caregiver throughout the facility. LPA did not observe any additional health or safety issues. However, pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is hereby cited (refer to LIC 809-D) based upon LPA's observation.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to Caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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Document Has Been Signed on 09/09/2022 05:24 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/09/2022 at 04:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CORNERSTONE FACILITIES, LLC
FACILITY NUMBER: 197609628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2022
Section Cited
HSC
1548(b)(3)

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1548(b) (3) The department shall assess an immediate civil penalty of five hundred dollars .. per violation and...($100) for each day the violation continues after citation for any of the following serious violations: (3) Absence of supervision, as required by statute or regulation.
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Administrator will review with staff the policies regarding the safety of residents.and will provide an LIC 500 to LPA
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 This requirement was not met: Upon LPA arriving to the facility, LPA observed there were no staff present at the facility and a resident was outside the facility waiting for the arrival of a staff member.
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Because this violation resulted in residents along at the facility without caregivers present, an immedaite civil penalty in the amount of $500 is issued.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
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