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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803484
Report Date: 12/02/2023
Date Signed: 12/02/2023 02:28:40 PM


Document Has Been Signed on 12/02/2023 02:28 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: 89DATE:
12/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Shelley Reyes, Administrator TIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced on 12/02/2023 at approximately 9:20 AM to conduct an annual inspection. LPA was allowed access to facility by receptionist. Administrator Shelley Reyes was contacted and arrived shortly. There were 89 residents.

LPA inspected 5 personnel and 5 resident files and found them to be complete. LPA then toured the facility with Care Coordinator Irene Heryford. 10 out of 10 rooms were found to be clean and furnished appropriately, with water temperature measuring between 110 - 116 degrees F, which is within regulation. Rooms were found to be a comfortable temperature. The facility was a comfortable temperature and passageways were free from obstructions. Visitor bathrooms are equipped with paper towels and handsoap. The Great Room was adorned with a large Christmas Tree and other holiday decor. The dining room was clean, sanitary and equipped for table service for the residents, with regular and alternative meal choices. The kitchen was clean and sanitary, and equipment was stored appropriately. There was adequate perishable and nonperishable food as required per regulation. LPA noted an Activity Room with arts and crafts available, a Game Room, a Beauty Salon (open several hours each week), a Library and ample outside areas which provide cover from the elements.

Fire extinguishers were last serviced December 14, 2022. The Fire Department conducted an inspection on 02/08/2023. Emergency drills are conducted quarterly. An emergency/fire/earthquake drill was done at the end of November.
Continued on 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CORNERSTONE ASSISTED LIVING
FACILITY NUMBER: 486803484
VISIT DATE: 12/02/2023
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Continued from 809

LPA requested proof of Liability Insurance.

There were no deficiencies found at the time of inspection. No citations issued.

This report was reviewed with Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023
LIC809 (FAS) - (06/04)
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