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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609628
Report Date: 10/27/2021
Date Signed: 10/27/2021 12:45:56 PM

Document Has Been Signed on 10/27/2021 12:45 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:
10/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Latasha MoodyTIME COMPLETED:
09:00 AM
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LPA Spaeth conducted an unannounced visit at 8:30 am and was greeted by Caregiver, Latasha Moody. Upon arrival, LPA observed the COVID sign on the front door. LPA's temperature was taken and was asked the COVID questions. AT 8:36 am, LPA signed the sign sheet sheet. Caregiver confirmed there are four residents in the facility and the residents were just getting up.

LPA stated the purpose of the visit was regarding an incident report that stated a resident had left the facility on October 21, 2021. The report stated a caregiver followed the resident and tried to redirect the resident multiple times. However, the resident would not comply. The report stated the resident met a friend at a fast food restaurant and left in the friend's car. The Administrator filed a police report. The resident returned to the facility on October 23, 2021 and was intoxicated. The staff called 911 and resident was admitted to the Antelope Valley Hospital. Administrator previously stated on October 25, 2021 via phone at 9:00 am that Administrator and staff are closely monitoring the resident.

At 8:55 am LPA conducted a tour of the facility. LPA observed both bathrooms contained the wash your hands sign, hand soap, paper towels, and trash can. Both parties then observed the locked garage which contained a six month supply of PPE, the knives, and a refrigerator which contained dairy products and frozen meets. Upon entering the kitchen, LPA observed the locked cabinet for resident medications and an adequate supply of fresh vegetables, meats, frozen vegetables, and canned goods.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report provided to the Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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