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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700267
Report Date: 03/11/2021
Date Signed: 03/11/2021 10:50:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CORNERSTONE SENIOR CAREFACILITY NUMBER:
342700267
ADMINISTRATOR:BOTH, GABRIELAFACILITY TYPE:
740
ADDRESS:8530 KRANS CT.TELEPHONE:
(916) 865-7259
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 0DATE:
03/11/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gabriela Both, Licensee TIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) McCrory contacted Licensee Gabriela Both, via FaceTime tele-visit to conduct a virtual inspection proceeding the closure of the facility. A Notice of Facility Closure was received by the Regional Office with a facility closure date of 3/01/2021. The visit was conducted via tele-visit due to COVID-19 and precautionary measures.

LPA observed interior/exterior of the facility, including front yard and fenced back yard with three exits, living room with a brown sectional, dining room with a brown table that seats four (4), kitchen, one (1) Private Room with bathroom, two (2) Shared rooms, one (1) Private room, and one (1) hallway bathroom. LPA observed that there were no residents at the facility.

LPA advised Licensee to mail the original License to the Regional Office and that the facility will be closed in the system as of 3/01/2021. A copy of this report has been emailed to the Licensee and the Licensee was advised that a signed copy of this report shall be submitted to Community Care Licensing Department (CCLD) within 10 days of receipt of this report.

Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jasmine McCroryTELEPHONE: (916) 214-5020
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021
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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