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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701389
Report Date: 11/19/2024
Date Signed: 11/19/2024 09:35:34 AM

Document Has Been Signed on 11/19/2024 09:35 AM - 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 CARE IIFACILITY NUMBER:
342701389
ADMINISTRATOR/
DIRECTOR:
CRUZ-MADURO, CYNTHIAFACILITY TYPE:
735
ADDRESS:7632 COFFER COURTTELEPHONE:
(916) 667-9101
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 4CENSUS: 0DATE:
11/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Cynthia Maduro-Cruz and Samuel Maduro TIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Christina Valerio and Licensing Program Manager (LPM) Stephen Richardson arrived announced to conduct a pre-licensing inspection. LPA Valerio met with Licensee/Administrator Cynthia Maduro-Cruz and Samuel Maduro, and explained the purpose of the visit.

The facility is approved to serve individuals 18 to 59 years of age. The facility has an approved fire clearance "for four (4) ambulatories where one (1) can be non-ambulatory in room #4." The facility is a five bedroom home, which room #1, #2, #3, and #4 will be utilized as a resident bedroom. Room #5 is designated to be a staff room only.
LPA Valerio observed the facility to have ring camera located at the front entrance of the facility. This will be used for security purposes. There were no other cameras observed inside of the facility. LPA Valerio inspected four resident rooms. Room #4 was observed to have an exit door with a walk way that is compliant. Room #4 has their own bathroom equipped to serve an individual considered to be non-ambulatory. A skid matt, hand rails, paper towels, toilet paper, and a trash can was observed. Other resident bedrooms were observed to be fully furnished and observed to have a door that is able to lock. The common bathroom was observed to be fully stocked with hygiene supplies and fully operational. The hot water was measured within the regulatory range of 105-120.0 degrees F. The staff bedroom was observed to be fully furnished with their own bathroom. The laundry room was observed to have a washer, dryer, and a cabinet for cleaning supplies. The kitchen was observed to be fully operational. The pantry and snack items will be accessible to residents in care. LPA observed where perishable and non-perishable food items will be stored. The facility has a lock box located in a cabinet for sharp items. LPA observed the carbon monoxide detector, fir extinguisher, and fire alarm to be in compliance and working condition. The exterior area was observed to have a shaded area for outdoor activities, a shed for storage items, and walk ways that were clear of obstruction.

Pre-Licensing is complete and this facility has no deficiencies. LPA to inform their CAB analyst of the inspection. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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