486803484-5-12-2021-21-AS-KMOA-C35PYB-20210518114337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803484
Report Date: 05/12/2021
Date Signed: 05/12/2021 04:10:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2020 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20200928122311

FACILITY NAME:	CORNERSTONE ASSISTED LIVING		FACILITY NUMBER:	486803484
ADMINISTRATOR:	SHELLEY REYES		FACILITY TYPE:	740
ADDRESS:	40 ORANGE TREE CIRCLE		TELEPHONE:	(707) 592-1157
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	130	CENSUS: 88	DATE:	05/12/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Shelley Reyes, Administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Facility staff failed to provide adequate supervision resulting in resident sustaining injury from a fall
Staff spoke inappropriately towards resident
Facility failed to notify the responsible party and Dr. of an observed change of condition
Facility failed to ensure residents dietary needs were being met
Staff are falsifying residents chart

INVESTIGATION FINDINGS:

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On 5/12/2021 Licensing Program Analyst (LPA) Tobola conducted a complaint investigation regarding the above allegations. Due to COVID-19 restrictions LPA Tobola met with Administrator Shelley Reyes by tele-visit. Facility was toured, facility resident and medical records were reviewed and interviews with staff, residents and other outside parties were conducted.

The complaint alleges facility staff failed to provide adequate supervision resulting in resident sustaining injury from a fall. Based on a review of incident report, resident records and interviews with staff and residents LPA found that staff conducted 2 hour room checks as outlined in R1's Care Plan. R1 also had access to 3 call lights in their apartment when assistance was needed. Based on a review of R1's care notes and interviews with staff LPA was found that R1 was involved in an unwitnessed fall while attempting to use the restroom without requesting for assistance. R1's care plan states that R1 is to request for hands on assistance when using the restroom.

Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 21-AS-20200928122311

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CORNERSTONE ASSISTED LIVING	FACILITY NUMBER: 486803484
	VISIT DATE: 05/12/2021

NARRATIVE

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Complaint alleges staff spoke inappropriately towards resident. Based on interviews with staff and residents LPA received statements and information that were contradicting to the Complainant's allegation. LPA was unable to find witnesses or evidence that supported inappropriate verbal actions from staff.

Complaint alleges facility failed to notify the responsible party and Dr. of an observed change of condition. Upon review of R1's care notes, R1's incidents and changes of condition were recorded and notified to R1's family. Upon review of R1's weight records from 2018-2020 staff documented R1's weight every other month. Staff protocol is to notify a resident's family and doctor if there is a weight change between 5-10lbs. Records indicate that R1 was not weighed from June 2020 to August 2020 due to refusal. However, the recorded weights for R1 from 2018-2020 do not indicate any significant change requiring notification to family and doctor.

Complaint alleges facility failed to ensure residents dietary needs were being met. Based on interviews with staff and residents it was found that the facility offers residents 3 meals a day with options for snacks in between meals. Based on interviews with residents and staff LPA found that two options are provided per meal with additional alternate options of sandwiches, soup and salad. Based on interviews with staff LPA found that R1 did not require any special diet but would skip 1 of 3 meals per day. In addition R1 was provided with food from family and meals from the facility directly to R1's room.

Complaint alleges that staff are falsifying residents chart. Based on a review of R1's care plan and Physician's Report, LPA learned that R1's Physician's Report was completed and signed by R1's Physician and not the facility staff. Based on interviews with staff and Administrator LPA was informed that staff only input diagnosis information received from R1's Physician. LPA was unable to find supporting evidence of staff altering or falsifying R1's charts.

A finding that the complaint allegations facility staff failed to provide adequate supervision resulting in resident sustaining injury from a fall, staff spoke inappropriately towards resident, facility failed to notify the responsible party and Dr. of an observed change of condition, facility failed to ensure residents dietary needs were being met and staff are falsifying residents chart are unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited during the visit. Signatures on file and Appeal Rights given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2020 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20200928122311

FACILITY NAME:	CORNERSTONE ASSISTED LIVING		FACILITY NUMBER:	486803484
ADMINISTRATOR:	SHELLEY REYES		FACILITY TYPE:	740
ADDRESS:	40 ORANGE TREE CIRCLE		TELEPHONE:	(707) 592-1157
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	130	CENSUS: 88	DATE:	05/12/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Shelley Reyes, Administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Staff removed residents call button

INVESTIGATION FINDINGS:

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On 5/12/2021 Licensing Program Analyst (LPA) Tobola and the Department conducted a complaint investigation regarding the above allegation. Due to COVID-19 restrictions LPA Tobola met with Administrator Shelley Reyes by tele-visit. Facility resident and medical records were reviewed and interviews with staff, residents and other outside parties were conducted.

The complaint alleges staff removed resident's call button. Based on a tour of the facility and interviews with staff and residents LPA was unable to find any obstructed or removed resident call lights. Each resident room is equipped with 2 to 3 call lights installed to the wall of the bedroom, living room and bathroom. LPA was unable to find evidence of R1's use of a personal call button. Based on a tour and interviews with both staff and residents and LPA found that staff respond to activated call lights within 5-10 minutes or less.

This agency has investigated the complaint alleging staff removed resident's call button. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited during the visit. Signatures on file and Appeal Rights given.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 3