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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701389
Report Date: 09/25/2025
Date Signed: 09/25/2025 04:33:04 PM

Document Has Been Signed on 09/25/2025 04:33 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 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: 1DATE:
09/25/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Cynthia Cruz Maduro, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 09/25/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct a post-licensing visit. LPA Campbell met with Maritess Burog, Caregiver and Cynthia Cruz Maduro, Administrator and explained the purpose of the visit. This post-licensing visit occurs due to the arrival of the first resident on 06/22/2025 after the community received their license on 11/21/2024

Upon entry to the community, staff provided access to LPA Campbell who observed a clear well lit space without odor or obstructions. A resident was observed watching television in the living room. LPA Campbell conducted a tour of the community consisting of the living room/common area, kitchen, bathroom, bedrooms and outdoor space. The kitchen contained more than 2 days of perishable items and LPA Campbell observed more than 7 days of non-perishables in the pantry. The hot water in the kitchen was measured at 114 degrees Fahrenheit (F). The freezer temperature measured 0 degrees F and the refrigerator was 37 degrees F. A fire extinguisher was observed that was purchased on 06/11/2025. The hot water temperature in the bathroom was measured to 115.8 degrees F.

The facility is a one story building licensed to serve developmentally disabled adults 18 through 59. It is approved for four ambulatory residents and one non-ambulatory resident in room #4. Each resident will have their own room and there is a staff bedroom for the licensees who reside in the community. An alteration to the buildings floor plan was made without notice to the Department and no building permit was obtained per the licensee.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil  penalties.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/25/2025 04:33 PM - It Cannot Be Edited


Created By: Renee Campbell On 09/25/2025 at 03:52 PM
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 II
FACILITY NUMBER: 342701389

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2025
Section Cited
CCR
80086(a)(b)

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Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
The licensing agency shall have the authority to require... a building inspection by a local building inspector..This requirement is not met as evidenced by:
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Licensee shall submit plans for alterations to the city to obtain a permit which will be provided to the Department, and construction inspected by a local contractor. A new fire clearance will then be completed. Documentation will be provided to the LPA by the POC due date by email.
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Based on observation and licensee statement, notification of construction or alterations was not provided to the Department which poses a potential Health, Safety or Personal Rights risk to person 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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Renee Campbell
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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