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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005435
Report Date: 04/22/2024
Date Signed: 04/22/2024 12:23:17 PM


Document Has Been Signed on 04/22/2024 12:23 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



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: DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Angelie UrsabiaTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by Angelie Ursabia, caregiver and LPA explained the nature of the visit. There are five residents at the facility and there are three residents receiving hospice services currently.

LPA accompanied began the tour of the inside and outside of the facility. Upon entry LPA observed residents in the living room watching a movie. LPA observed required department postings at the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in storage spare refrigerator located in the garage. LPA at the time of visit observed caregiver preparing residents lunch meals. LPA observed caregivers assist with feeding of those required residents their lunch and observed caregivers bringing resident to the meal table for lunch. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 110.8 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked storage cabinet garage. The facility has an available clean supply of linens in hallway storage. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways

Continued on LIC809-C
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CORNERSTONE HOMES
FACILITY NUMBER: 306005435
VISIT DATE: 04/22/2024
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are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA observed a fire extinguisher mounted in the kitchen. Fire drills are conducted every three months. LPA began review of records. LPA reviewed three resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
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