<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609628
Report Date: 01/20/2022
Date Signed: 01/20/2022 03:18:18 PM

Document Has Been Signed on 01/20/2022 03:18 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:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jhomer YusonTIME COMPLETED:
03:30 PM
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
LPA Spaeth conducted an unannounced visit and was greeted by caregiver Jhomer Yuscon. Upon approaching the facility, LPA observed the COVID signs on the front door. Upon entering, LPA's temperature by caregiver, and COVID questions were asked by the caregiver. The caregiver confirmed there are four residents in the facility. LPA observed two residents come into the facility and caregiver provided help to the residents when residents asked for help. The Caregiver confirmed a resident was sleeping in the master bedroom and a resident was attending classes at a school location. LPA also observed sign in station with hand sanitizer, masks, and sign in sheet. LPA was escorted to the living room, kitchen and dining room combination. LPA observed comfortable seating in the living room along with a television.

LPA and Caregiver began to tour the facility at 1:20 pm. LPA observed the kitchen was clean and observed there was an adequate supply of frozen meats and vegetables in the frozen section of the refrigerator. The refrigerator contained a supply of fresh vegetables and other items in the refrigerator. LPA observed wash your hands sign, hand soap, and paper towels at the kitchen sink. The cabinet underneath the sink was empty and all medications were locked in a kitchen cabinet.

LPA observed a resident's room near the kitchen. The room contained a bed, linens, night stand, lamp and chest of drawers. LPA Spaeth observed the backyard contained comfortable furniture and observed the gate that leads to the front yard was unlocked.

The dining room contains a dining room table, office furniture and a locked cabinet which contains the residents' files. The resident bathroom contains wash your hands sign, hand soap, paper towels, and a trash can. LPA was then escorted to the garage and observed an additional refrigerator which contained food for the facility. the knives were locked in a cabinet and there was a 60-day supply of PPE available for staff use.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/20/2022
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
LPA and Caregiver then walked to the east side of the facility. There are two bedrooms and the resident bathroom within that section of the faclity. LPA observed locked cabinets which contained cleaning supplies. LPA also observed the laundry detergent was locked in a hallway closet.

There are no deficiencies to report at this time. Exit interview was conducted, appeal rights discussed, and a copy of the signed report was given to the caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2