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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803484
Report Date: 10/22/2024
Date Signed: 10/22/2024 02:40:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2024 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20241014153520
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
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Shelley Reyes, AdministratorTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in a resident wandering away from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Julie Florio arrived unannounced to initiate a 10-day complaint investigation, regarding the allegation listed above for complaint 21-AS-20241014153520 received by Community Care Licensing (CCL) on 10/14/2024, and met with Shelley Reyes, Administrator.

During inspection LPA obtained documents, made observations, and conducted interviews (see LIC812s). The complaint alleges that on 10/13/2024, at approximately 4:30 PM, Resident 1 (R1) was found wandering in the nearby shopping center by a concerned bystander. Facility self reported R1's elopement from the community on an Unusual Incident/Injury Report (UIR) submitted to CCL on 10/16/2024. The UIR stated on 10/13/2024 R1 left the facility and was found by Kohl's security in the shopping center's parking lot. CCL's Officer of the Day requested the facility submit R1's LIC602 Physician's Reports and Appraisal Needs and Services Plan to CCL, which facility submitted on 10/17/2024. Per R1's LIC602 dated 01/03/2022, they have Mild Cognitive Impairment (MCI) and are unable to leave the facility unassisted.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20241014153520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
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Continued from LIC9099...

The allegation, staff did not provide adequate supervision resulting in a resident wandering away from the facility is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency was cited on LIC9099-D, per Title 22 Regulations, Division 6.

Exit interview conducted. Appeal rights given. Copy of report discussed and provided to Administrator whose signature on form confirms receipt of document(s).
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241014153520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87468.2(a)(4)
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87468.2(a) … [R]esidents ... shall have […] the following personal rights: (4) To...supervision...that meet their individual needs.... This requirement was not met as evidenced by:
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Administrator to provide in-service training for all staff to be alert and aware of residents wandering and/or exiting the facility and review of the facility's protocols in these situations.
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Based on review of facility submitted UIR, resident record review, and interviews with facility staff, facility did not provide adequate supervision for R1, which resulted in R1's elopement from the facility. This poses an immediate health, safety, and personal rights risk to residents in care.
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Administrator to submit scheduled training date to CCLD by POC date 10/23/2024 and submit completed signed training log to CCLD by POC due date 11/8/2024 EOB.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3