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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803484
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:39:47 PM


Document Has Been Signed on 05/09/2024 03:39 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CORNERSTONE ASSISTED LIVINGFACILITY NUMBER:
486803484
ADMINISTRATOR:SHELLEY REYESFACILITY TYPE:
740
ADDRESS:40 ORANGE TREE CIRCLETELEPHONE:
(707) 999-5029
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:130CENSUS: DATE:
05/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Nakagawa and Mutialu were at facility to conduct case management. LPAs met with Administrator Shelley Reyes. The purpose of this case management is to follow up on a self-reported incident report submitted to Community Care Licensing (CCL).

CCL received a self reported incident report on 04/24/2024 reporting on 05/01/2024. At 4:30 AM care staff went to check on resident (R1) and R1 was not in their apartment. Care staff and Medication Technician reported they conducted a search of building and were unable to locate R1. At that time care staff called 911. Dispatch reported R1 had been located and taken to hospital for evaluation.

LPA reviewed physician's report which states that R1 has memory loss and is at risk if allowed to leave the community unsupervised due to dementia or cognitive decline, as well as a high fall risk. Facility is being cited for Regulation 87705(b)(2)(see LIC809-D).

The following deficiencies were observed (see LIC 809D) 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 and appeal of rights provided.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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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Document Has Been Signed on 05/09/2024 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: CORNERSTONE ASSISTED LIVING
FACILITY NUMBER: 486803484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
Section Cited
CCR
87705(b)(2)

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87705 Care of Persons with Dementia (b)In addition to the requirements as specified in Section 87208..., the plan of operation shall address the needs of residents with dementia, including:Safety measures to address behaviors and ingestion of toxic materials. This requirement is not met as evidenced by:
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Administrator to ensure all exits have working auditory alarms that staff can hear or receive a signal when doors are opened. In addition Administrator to provide
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Based on record review, self-incident report dated 05/01/2024, and interviews with Administrator, R1 eloped without staff knowledge on 4/24/2024. The facility did not comply with section above,when R1 eloped from facility, which poses an immediate Health, Safety risk to residents in care.
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proof of scheduling of elopement training for staff (by EOB 5/10/2024). Administrator to reassess R1 for change in condition.

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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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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