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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609628
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:04:50 AM

Document Has Been Signed on 12/15/2022 11:04 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:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica CruzTIME COMPLETED:
11:00 AM
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 the Licensee and the house manager. LPA stated the purpose of the visit. Licensee left the facility at 10:15 am, Upon entering, LPA's temperature by caregiver, and COVID questions were asked by the house manager. The house manager confirmed there are four residents in the facility. LPA observed two residents waiting for transportation to a adult day program. Also, House Manager confirmed one resident was in own room during LPA's visit.

LPA and House Manager toured the facility at 10:00 am until 10:20 am. LPA observed comfortable seating and a television in the living room and the dining room area contained tables and chairs. The kitchen was clean and the House Manager unlocked the cabinet underneath the kitchen sink which contained cleaning supplies. Another kitchen cabinet was unlocked and LPA observed the resident's medications and knives. LPA observed a two-day supply of perishable foods and a seven-day supply of non-perishable foods in the pantry. LPA observed wash your hands sign, hand soap, and paper towels at the kitchen sink.

There are four resident bedrooms in the facility. LPA observed three bedrooms which 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 two bathrooms contained 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. LPA observed the laundry room; the laundry soap was safely locked in a cabinet. LPA also observed the linen cabinet which contained clean linens.

There are no deficiencies to report at this time. Exit interview was conducted, 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: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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 1