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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005902
Report Date: 02/04/2025
Date Signed: 02/04/2025 04:41:11 PM

Document Has Been Signed on 02/04/2025 04:41 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CORNERSTONE CRISIS RESIDENTIALFACILITY NUMBER:
317005902
ADMINISTRATOR/
DIRECTOR:		JENNA ALLENFACILITY TYPE:
772
ADDRESS:101 CIRBY HILLS DRIVETELEPHONE:
(916) 788-8144
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 14CENSUS: 13DATE:
02/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Jenna AllenTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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On 2/4/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with Administrator .

The department received 5 incident reports for client missed medication.
LPA reviewed the reports with the Administrator as well as reviewing programs medication procedures.
The medication errors involved R1, on 1/25/25 and 1/27/25, R2, on 1/25/25 and 1/26/25, and R3 on 2/1/25. The 25th -27th errors were discovered in medication audit. Those staff responsible will be determined and retraining provided. The staff responsible for the 2/1/25 error , S1, is currently under supervisory review.

As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of report and appeal rights provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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Document Has Been Signed on 02/04/2025 04:41 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 02/04/2025 at 04:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CORNERSTONE CRISIS RESIDENTIAL
FACILITY NUMBER: 317005902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2025
Section Cited
CCR
81075(b)

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81075 HEALTH-RELATED SERVICES
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met based on incident reports and interview.
This posed an immediate risk to residents.
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Licensee agreed to submit policy for supervision of medication errors as well as actions taken with staff to correct errors that occurred. Additionally, a statement will be submitted for all staff medication training to occur by the end of the month.
POC due by 2/5/25,

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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