<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803484
Report Date: 10/22/2024
Date Signed: 10/22/2024 03:30:25 PM


Document Has Been Signed on 10/22/2024 03:30 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
SANTA ROSA RO, 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: 93DATE:
10/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Shelley Reyes, AdministratorTIME COMPLETED:
03:45 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
On 10/22/2024, at approximately 12:40 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident follow up visit regarding 5 Unusual Incident/Injury Reports (UIRs) and 1 Death Report received by Community Care Licensing (CCL) between 09/23/2024 and 10/22/2024. LPA met with Shelley Reyes, Administrator. Facility is an assisted living community

Incident #1 Received by CCL on 09/23/2024: On 09/22/2024, Resident 1 (R1) was given 1/2 tab instead of the doctor ordered 1/4 tab of Metropalol succ ER 25mg due to a pharmacy error. The pharmacy filled the incorrect quantity and this was discovered by the Facility's med tech after the medication had been given to R1. The Pharmacy was contacted and R1 was placed on 72 hour monitoring for any change in condition. A corrected prescription was processed by the pharmacy and sent to the facility. R1 did not report any change in condition.

Incident #2 Received by CCL on 10/7/2024: On 10/4/2024, Resident 2 (R2) was "accidentally given Protonix 40mg medication" (See LIC809D). R1's primary care physician (PCP) and family were notified and R1 was placed on 72 hour monitoring for any change in condition. R1 did not report experiencing any adverse affects.

Incidents #3 & #4 Received by CCL on 10/7/2024 & Death Report Received by CCL on 10/08/2024: On 10/3/2024, Resident 3 (R3) "had an unwitnessed fall and was found on the floor in [their] apartment by staff when doing safety checks." Another UIR for the same incident stated R3 "had a fall and had leg pain." EMS was called, R3 was sent to the ER, and later R3's family called the facility to report that R3 passed away due to Heart Failure on 10/4/2024. R3 was not on Hospice. On 10/7/2024, the CCL Officer of the Day requested a death report be submitted. Death Report was received on 10/8/2024 and stated that a copy of the death certificate would be requested. Based on record review, R3 was found at 4:00 AM on 10/3/2024.

Continued on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CORNERSTONE ASSISTED LIVING
FACILITY NUMBER: 486803484
VISIT DATE: 10/22/2024
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
26
27
28
29
30
31
32
Continued from LIC809...

Facility Administrator provided LPA with a copy of R3's Death Certificate which states cause of death: Cardiogenic Shock, Acute Hypoxemic Respiratory Failure, and Acute On Chronic Congestive Heart Failure.

Incident #5 Received by CCL on 10/21/2024: On 10/14/2024, Resident 4 (R4) "was found on the floor when call light was answered. 911 was called. Resident was taken to the ER for further evaluation." The report states that R4 was discharged to a skilled nursing facility (SNF) on 10/17/2024. Per record review, R4 had previous falls on 7/18/2024 and 9/20/2024 which were not reported to CCL (See LIC809D).

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Administrator.

Exit interview conducted with Administrator, whose signature on document(s) confirms receipt.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/22/2024 03:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: CORNERSTONE ASSISTED LIVING
FACILITY NUMBER: 486803484

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
87465(a)(4)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) …. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee has already conducted medication training on ensuring the correct medication and dosages are given to residents in care per the physician's order. Additionally, Licensee counselled the staff member who made the medication error.
8
9
10
11
12
13
14
Based on observation, interviews, and record review, the Licensee did not ensure R2 received the correct medication as prescribed which poses an immediate health, safety, and/or personal rights risk to residents in care.
8
9
10
11
12
13
14
LPA cleared POC during today's visit.
Type B
11/22/2024
Section Cited
CCR87211(a)(1)

1
2
3
4
5
6
7
87211 (a)(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of…. (D) Any incident which threatens the welfare, safety or health of any resident….This requirement was not met as evidenced by:

1
2
3
4
5
6
7
Licensee will conduct in-service training with all care staff on the proper reporting requirements as outlined in CCR 87211.
8
9
10
11
12
13
14
Based on observation, interviews, and record review, the Licensee did not ensure CCL received Unusual Incident/Injury reports for two falls R4 experienced which poses a potential health, safety, and/or personal rights risk to residents in care.
8
9
10
11
12
13
14
Licensee will submit a signed training log with names of attendees, date, time, location and subject of the training, and who conducted the training to CCL by POC due date 11/22/2024.
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3