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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005408
Report Date: 05/14/2021
Date Signed: 05/14/2021 11:57:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CORNERSTONE HOMESFACILITY NUMBER:
306005408
ADMINISTRATOR:SATHER, JOSEPHFACILITY TYPE:
740
ADDRESS:27076 LOST COLT DRIVETELEPHONE:
(949) 360-4314
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 6DATE:
05/14/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Evangeline De VeraTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this case management visit for the purpose of a health and safety check. Six (6) residents currently reside at this location and hospice services are being provided to two (2) residents at this time. LPA arrived at facility was greeted at the door by caregiver and granted entry.

Upon entry LPA observed one caregiver in kitchen doing meal preparation and six residents in their bedrooms.

During the case management visit LPA took a tour of the inside of the facility, restrooms and common areas. LPA observed that the meal prepared appeared of good quality and storage areas organized. LPA inspected food supply adequate amount was observed to be within regulations. The facility has a two-day supply of perishables and seven-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction. There are no health and safety concerns observed in facility.

During the visit LPA observed there were COVID-19 precautionary measure through out the facility. LPA spoke with caregivers regards to any concerns within the facility. LPA spoke with alert residents regarding the quality of their care.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations.

This report was reviewed with caregiver and a copy of this LIC809 was provided to the facility.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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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