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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609628
Report Date: 12/06/2022
Date Signed: 12/06/2022 11:02:01 AM

Document Has Been Signed on 12/06/2022 11:02 AM - 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:
12/06/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anderson MunozTIME COMPLETED:
10:45 AM
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An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss the deficiency cited at the facility during a case management visit conducted on 9/09/2022. Prior to the meeting, the Licensee was given the opportunity to review the facility file.

Present at today's meeting are the following:
· Anderson Munoz, Licensee
· Cassandra Harris, Licensing Program Manager (LPM)
· Melissa Spaeth, Licensing Program Analyst (LPA)

The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions.

BRIEF HISTORY: Facility has been in operation since licensure on 1/25/2019, for a maximum of four residents.


LPM Harris discussed and expressed concerns regarding the citation related to the case management visit conducted by LPA Spaeth on 9/09/2022. LPA knocked at 3:35 pm but no one was at the facility. LPA spoke to Administrator at 3:45 pm and was told staff would be returning to the facility. At 3:46 pm, LPA observed resident (R1) exit the backyard to the front yard. R1 stated was waiting for staff to return to the facility. LPA observed Administrator arrived at the facility at 4:00 pm.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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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: 12/06/2022
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Licensee/Administrator shall submit the following by December 13, 2022:
· An updated LIC 500 - Personnel Report
· Facility policy and procedures regarding staff leaving facility/running errands
· Provide staff training regarding above policy and procedures
· Provide sign in sheet of staff participating in policy training.

The Licensee was informed that Community Care Licensing (CCL) shall continue to monitor the facility with annual facility inspection visits and as often as necessary to ensure the Licensee's compliance with Title 22 Regulations. The Licensee was also informed that further citations and/or non-compliance may result in a Non-Compliance Conference with the Regional Manager.

Exit interview conducted and copy of today's report was provided to the Licensee..
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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