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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005902
Report Date: 08/02/2022
Date Signed: 08/29/2022 03:42:34 PM

Document Has Been Signed on 08/29/2022 03:42 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CORNERSTONE CRISIS RESIDENTIALFACILITY NUMBER:
317005902
ADMINISTRATOR:DAVIS, HEATHERFACILITY TYPE:
772
ADDRESS:101 CIRBY HILLS DRIVETELEPHONE:
(916) 788-8144
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 14CENSUS: 10DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Enrique TamayoTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/2/22 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with associate director and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and self assessment. LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Administrator was unavailable for the inspection.

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and associate director completed the infection control domain and facility was found to be in basic compliance at this time.

LPA advised: More robust screening of visitors, staff and clients for known symptoms and consistent documentation; increased signage and PIN information be available to clients and staff; Human Resources submit proof of weekly testing for staff who require it; HR review the Guardian staff roster to ensure all staff are associated; Increase encouragement and education of client to use mask and maintain physical distance in common areas; and provide Fit Testing to staff for N-95 use.
LPA will email additional resources and information.

LPA requested for documents such as LIC 500, Administrator's Certificate and last page of LIC 610E Documents to be submitted to LPA via email by due date 8/12/22.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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