197609628-1-5-2022-31-AS-CHAS-CBAU5W-20220203141725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609628
Report Date: 01/05/2022
Date Signed: 01/05/2022 05:13:51 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
05/25/2021 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20210525163243

FACILITY NAME:	CORNERSTONE FACILITIES, LLC		FACILITY NUMBER:	197609628
ADMINISTRATOR:	KING, MARLON		FACILITY TYPE:	735
ADDRESS:	504 W AVE H13		TELEPHONE:	(818) 687-3830
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	4	CENSUS: 3	DATE:	01/05/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jessica Cruz-Semick		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff denied resident from being seen by a physician

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Spaeth conducted an unannounced visit to the facility and was greeted by staff member, Jessica Cruz -Semick (S1). Upon arrival, LPA observed the COVID signs on the door and LPA's temperature was taken, COVID questions were asked by S1, and LPA observed the sign in station at the front door. LPA observed S1 and all residents were wearing masks. LPA stated the purpose of the visit is to give the findings of the alleged complaint which states, staff denied resident from being seen by a physician. LPA interviewed three residents from 3:30 pm until 3:50 pm.

The complainant had stated a resident (R1) called the complainant during the month of May, 2021 stating needed to go to the doctor but staff were refusing to take R1. LPA asked for the name of the facility staff member who refused to call doctor. Complainant was not provided the name of the staff member.

LPA Spaeth interviewed the Administrator and House Manager on January 3, 2022. Both confirmed staff members have never denied resident the opportunity to go the doctor when needed and staff has always

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

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-20210525163243

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: 01/05/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

taken R1’s statement regarding pain seriously. Administrator stated the Los Angeles Sheriff’s Department Medical Team was called during the month of May, 2021 when R1 stated was experiencing pain and experiencing thoughts of suicide. LPA received the medical discharge papers from the Antelope Valley Hospital which states R1 was seen by an Antelope Valley Hospital doctor on May 25, 2021. Documentation states x-rays show rib area was normal which was the location of R1's pain. Based upon LPA interviewing the three residents, staff has never denied residents access to a doctor and has been helpful in assisting residents with doctor's appointments when needed.

On 10/27/2021 at 2:30 pm, LPA Spaeth conducted a phone interview with R1 but R1 could not remember requesting staff call 911 or call the doctor regarding pain in R1’s side and experiencing suicidal thoughts on May 24, 2021. R1 also stated does not remember this at all. Also, LPA asked if R1 called complainant stating facility staff would not assist R1 with medical needs. R1 stated could not remember and thought this did not happen. LPA Spaeth confirmed that R1 had moved out of the facility as of June 8, 2021.

On November 18, 2021, LPA spoke to Caregiver, Jessica Cruz-Semick at 3:45 pm. Caregiver stated R1 was experiencing pain in side and was experiencing suicidal thoughts. Caregiver stated S1 was transported to the Antelope Valley Hospital. LPA received a copy of the hospital medical records for R1 which confirms R1 was escorted to the hospital. Caregiver stated staff member from McKinnley Mental Health came on May 26, 2021 and Caregiver explained to staff member that R1 had been transported to Antelope Valley Hospital on May 25, 2021.

LPA Spaeth had previously left messages for the complainant on October 25, 2021, November 9, 2021, November 21, 2021 and December 23, 2021 to confirm complainant’s visit to the facility. However, LPA has not received returned telephone calls from the Complainant.

Based upon LPA’s interviews with facility staff members, interview of the residents, and LPA’s attempt to reach complainant, this complaint is unsubstantiated at this time.

Exit interview conducted, appeal rights discussed, and a copy of the signed report given to caregiver.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2