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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700385
Report Date: 03/11/2024
Date Signed: 03/11/2024 12:25:16 PM

Document Has Been Signed on 03/11/2024 12:25 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:CRUZ-MADURO, CYNTHIAFACILITY TYPE:
735
ADDRESS:9210 BROMFIELD CTTELEPHONE:
(916) 588-6448
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
03/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Cynthia Cruz-Maduro TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 3/11/24 at 10:45a to conduct an investigation of an incident where resident #1 possibly had a medication error and/or there was a records managment error in February 2024.

LPA met with Caregiver Ellen Fidel and stated the purpose of the visit. Ellen Fidel contacted the Administrator Cynthia Cruz-Maduro regarding todays visit. Administrator arrived within 15 minutes to assist with todays visit. LPA conducted interview with Administrator, and reviewed medication documentation for Resident #1 (R1).

Based on records review, documentation, and admittance of Administrator the investigation revealed that
the MAR was correctly handwritten but then incorrectly typed. However there was no medication error that occurred during the administration of medications.

Therefore, the preponderance of evidence standards has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit Interview held and a copy was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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 03/11/2024 12:25 PM - It Cannot Be Edited


Created By: Victoria Brown On 03/11/2024 at 11:52 AM
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 ADULT RESIDENTIAL CARE
FACILITY NUMBER: 342700385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2024
Section Cited
CCR
80070(a)

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Client Records

The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
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Licensee shall create a plan to ensure this records error does not occur.

POC cleared prior to todays visit.
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This requirement is not met as evidenced by: Based on records review, documentation, and admittance of Administrator the MAR was correctly handwritten but typed incorrectly as a final version. This violation poses a potential health, and safety risk to residents in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024


LIC809 (FAS) - (06/04)
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