<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700385
Report Date: 05/13/2024
Date Signed: 05/13/2024 02:52:08 PM

Document Has Been Signed on 05/13/2024 02:52 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CORNERSTONE ADULT RESIDENTIAL CAREFACILITY NUMBER:
342700385
ADMINISTRATOR/
DIRECTOR:		CRUZ-MADURO, CYNTHIAFACILITY TYPE:
735
ADDRESS:9210 BROMFIELD CTTELEPHONE:
(916) 588-6448
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 3DATE:
05/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Cynthia Cruz-MaduroTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a case management visit on 5/13/24 at 1:15p. LPA met with Cynthia Cruz-Maduro and stated the purpose of the visit.

Community Care Licensing (CCL) received an Incident Report (LIC624) indicating that resident #1 passed away at the facility.

CCL received the (LIC624A) Death Report dated 5/10/24, Individual Program Plan (IPP) dated 3/7/2024, (LIC602) Physician Report dated 1/10/24, (LIC627C) Consent for Emergency Medical Treatment dated 12/14/23.

LPA conducted an interview with Administrator who indicated that R1 was medication compliant, ate well with no complications and/or complaints, except for eye redness with no pain for which a doctors appointment had been scheduled for the day of the incident.

LPA met the relative of resident #1 (R1) who stated that a copy of the death certificate will be given to the facility who then in turn can send a copy to CCL.

At this time, there is no mention of cause of death. The relative is not sure yet.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited during this visit.

Exit Interview held, and a copy was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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 1