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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700385
Report Date: 04/22/2026
Date Signed: 04/22/2026 02:33:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20250819084625

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:
04/22/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cynthia Cruz-MaduroTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Personal Rights:
1) Staff did not follow resident's care plan.
2) Staff did not meet resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Cornerstone Adult Residential Care ARF on 4/22/26 at 9:30am to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations have been corroborated. The department conducted file review for R1 and conducted interviews with multiple staff, residents and reporting party. The department observed the pre-placement appraisal for R1 was incomplete and did not contain the required information and documetnation for identifying R1's needs and the developement of a client care plan. LPA reviewed R1's Individual Program Plan developed by alta regional center dated 12/9/2024 and observed the information documented to be outdated by the time of placement at this facility. R1's living arrangements and mental health had significantly changed by the time of R1's placement at the facility and did not reflect R1's current needs. Report continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20250819084625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 342700385
VISIT DATE: 04/22/2026
NARRATIVE
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Additionally, the facility did not obtain a physician's report for R1 prior to their placement in the facility which would have provided additional information of R1's potential needs and services to be provided by facility staff and assist in the development of a resident care plan. The facility did not conduct a thorough pre placement assessment and did not obtain enough information to establish and meet the needs of R1 while in care at the facility.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Other is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20250819084625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 342700385
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2026
Section Cited
CCR
85078(a)(1)
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Responsibility for Providing Care and Supervision: The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by review of R1's pre placement appraisal, outdated IPP and
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Facility will provide a written plan of correction indicating the steps facility will take to ensure all staff have reviewed resident's needs and services plan or IPP and will ensure all parties are in agreement including the proposed resident and their representatives prior to the resident being accepted
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physician's report which were incomplete and determined there was not an appropriate plan in place to meet the resident's need which resulted in physical altercations with staff and being arrested which poses an immediate health, safety and personal rights risk to resident's in care.
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Type B
04/30/2026
Section Cited
CCR
85068.2(a)
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Needs and Services Plan: Prior to admission, the licensee shall determine whether the facility's program can meet the prospective client's service needs. This requirement was not met as evidenced by LPA review of R1's file where LPA observed incomplete pre-
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Licensee agrees to provide a written plan of correction that includes the steps facility will take to ensure all documentation is obtained prior to a resident being accepted. Plan will also include how a needs and services plan is developed with that information and if there are discrepancies with existing plans that differ from licensee's observations of potential residents.
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placement appraisals, outdated IPP information and no physician's report which prevented licensee for accurately identifying the needs and services required for R1 to have a successful placement and poses a potential health, safety and personal rights 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7