486803484-12-21-2021-21-AS-KWAS-C9X3B8-20211221170554

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803484
Report Date: 12/21/2021
Date Signed: 12/21/2021 05:06:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 84	DATE:	12/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Adminsitrator, Shelley Reyes		TIME COMPLETED:	05:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Katrina Walters arrived unannounced to conduct an Annual inspection and was greeted by Marketing Director, Aida Reye Santos (ARS) and Administrator Shelley R Reyes (SR) (6012578740 exp. 1/31/2022) arrived later. LPA conducted a risk assessment prior to entering the facility. The inspection is focused on the Infection Control procedures and practices of this facility. This facilities COVID-19 mitigation plan has been submitted and approved by Community Care Licensing (CCL) 06/24/21. Prior to entering, LPA observed that COVID-19 signs and the visitors policy were posted on the front door. Upon entry, LPA was screened for COVID-19 symptoms and had temperature checked via sign in application on an I PAD, which then prints a badge out for visitors. LPA toured the facility with ARS. SR joined the tour later. Signs were posted through out the facility to promote social distancing and hand washing. The facility was clean and a comfortable temperature. In the event of an outbreak, both residents have their own room and will be isolate symptomatic residents. Emergency contacts have been updated. Facility has procedures for testing and isolating all individuals who are showing symptoms. Facility keeps track of all resident, staff and visitors vaccination records in their appropriate binders. Facility has a 30 day supply of Personal Protective Equipment (PPE) and incontinence product supply. All staff have been fit tested for N95 mask, and have received training on COVID-19 exposure through Local Public Health and Kaiser Permanante. Common Areas are disinfected after usage, using disinfectant sprayers. Continued on 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/21/2021

NARRATIVE

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LPA observed a visitor walking in common area without a mask. In addition, LPA disclosed to Administrator that facility staff failed to wear face covering while providing care and supervision to residents in this facility. S1 was observed transporting resident in common areas, and then observed not wearing a mask while providing care in residents bedroom. Facility failed to ensure staff followed COVID-19 precautions, CCL and CDC recommendations.

In addition, LPA observed that the two studio resident bedrooms were conjoined in order to make one resident suite. In doing so, one of the studio doors were blocked. LPA requested that Administrator have the bedrooms cleared by the fire department. Administrator agreed to submit an updated facility sketch to the Vacaville fire department by 1/3/2022.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, copy of this report and appeal of rights provided,

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87405(d)(1)

87405(d)(1) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(1)Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, facility staff failed to ensure staff S1 wears face mask coverings, while providing care to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/03/2022
	Plan of Correction
1 2 3 4	Facility to send in written plan, that all staff have knowledge of the requirements of Covid-19 precautions, CCL and CDC.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC809 (FAS) - (06/04)

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