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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005435
Report Date: 06/21/2022
Date Signed: 06/21/2022 10:17:42 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2020 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200918103932
FACILITY NAME:CORNERSTONE HOMESFACILITY NUMBER:
306005435
ADMINISTRATOR:DELA CRUZ, ERLINDAFACILITY TYPE:
740
ADDRESS:27052 LOST COLT DRIVETELEPHONE:
(949) 360-1379
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:6CENSUS: 6DATE:
06/21/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angelie UrsabiaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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-Staff did not report incident to CCL

-Staff administered insulin to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted at the door by Angelie Ursabia, caregiver and granted entry. LPA spoke with Joseph Sather, Administrator via telephone call and explained the purpose of the visit.

Findings are based upon this investigation which included file review and interviews conducted.
It is alleged that staff did not report incident to CCL. Per Department record review indicated that on 01/17/2020 received an LIC624 unusual incident for R1’s incident that occurred on 01/16/2020. It is alleged that staff administered insulin to resident in care. Per interviews conducted revealed that R2 would administer their own insulin injections. Once staff identified that R2 could no longer administer the insulin injections staff notified Joseph Sather, Administrator of change in condition. Administrator notified family of R2 of the change.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20200918103932
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CORNERSTONE HOMES
FACILITY NUMBER: 306005435
VISIT DATE: 06/21/2022
NARRATIVE
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Resident R2 was moved out of the facility on August 02, 2020. Base on the information received from interviews, the lack of information regarding the incidents in question, and the lack of corroborating witnesses to the incident, LPA is unable to determine if the alleged violations occurred as reported.

Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations is deemed Unsubstantiated.

An exit interview was conducted with facility representative and a copy of this LIC9099 report was left at facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2