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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317005902
Report Date: 08/29/2023
Date Signed: 08/29/2023 03:36:41 PM

Document Has Been Signed on 08/29/2023 03:36 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:DAVIS, HEATHERFACILITY TYPE:
772
ADDRESS:101 CIRBY HILLS DRIVETELEPHONE:
(916) 788-8144
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY: 14CENSUS: 9DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Daniel KrinsmannTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/29/23 to conduct a Annual Inspection utilizing the CARE Tool. LPA met with staff and explained the purpose of the visit. Visit conducted with Associate Director.

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 and patio. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA advised licensee that through observed water temperature variation, licensee monitor water temperatures in client living spaces.

LPA reviewed three client files and four staff files. Files are complete.

Emergency plan will be reviewed and updated as needed.

Ombudsman and CDSS Complaints posters will be replaced.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted with Director Heather Davis and copy of report left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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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