486803484-11-17-2025-21-AS-ECOS-DNJ42A-20251117174248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803484
Report Date: 11/17/2025
Date Signed: 11/17/2025 05:42:58 PM

Document Has Been Signed on 11/17/2025 05:42 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 LIVING		FACILITY NUMBER:	486803484
ADMINISTRATOR/ DIRECTOR:	SHELLEY REYES		FACILITY TYPE:	740
ADDRESS:	40 ORANGE TREE CIRCLE		TELEPHONE:	(707) 999-5029
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY: 130		CENSUS: 106	DATE:	11/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Shelley Reyes-Director		TIME VISIT/ INSPECTION COMPLETED:	06:00 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	At approximately 10:00am Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection visit and was greeted by Program Administrator (admin) Shelley Reyes. Facility is a Residential Care Facility for the Elderly (RCFE) with currently one hundred and seven (107) residents in care. Facility has a hospice waiver for twelve (12), a bedridden waiver for thirty (30), and is approved for all non-ambulatory residents. LPA and admin toured the buildings and grounds. Facility found to be at a comfortable temperature. All passageways and emergency exits were free from obstruction. LPA observed evacuation chairs on both stairways. Admin opened chairs and were observed to be functional. Elevator was operational and functional. Alarm system in exit door heading toward courtyard had minimal low volume, not loud enough to summon staff. Batteries were replaced. In addition, signal system heading toward back parking lot exit next to restrooms was not turned on. (Deficiency cited, see LIC 809D). Facility's fire extinguishers were observed charged and were last serviced 12/2024. Facility's fire system is hardwired though fire department. Four (4) water heaters throughout facility. Ten (10) residents' apartments were inspected and water temperatures in Residents' bathrooms and communal bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. Residents' bedrooms were inspected and observed to be clean with all the appropriate furnishings. The call system was tested in four (4) resident's rooms. Caregiver response time was 6 minutes and 17 seconds, 1 minute and 33 seconds, 1 minute and 50 seconds and 3 minutes and 50 seconds. Storage rooms containing cleaning supplies and other items that could pose a risk were locked. Continued to 809C...

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CORNERSTONE ASSISTED LIVING	FACILITY NUMBER: 486803484
	VISIT DATE: 11/17/2025

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continued from 809...

Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Facility kitchen and walk-in refrigerator and freezer were inspected and all food is being properly labeled and stored. LPA observed activity rooms including theater room, puzzle room and library room to be accessible for residents to use. Seating areas were observed in multiple outdoor courtyard spaces throughout the facility for activities.

Facility has two transportation vehicles including a bus and van for resident outings. LPA observed fire extinguishers up to date and last serviced 12/24. LPA observed first aid kit in both vans to have multiple expired items (Technical Violation given). Admin showed proof of order receipt for first aid kits to be replaced for both cars.

LPA reviewed nine (9) staff files and ten (10) resident files. All staff files reviewed have all of the required paperwork, proof of current First Aid and CPR training, and proof of all required training hours. Training certificates not placed in employee files, admin to send certificates to LPA by 11/19/25. Ten (10) of ten (10) resident files reviewed have all the required paperwork.

LPA reviewed medications and medication records which are maintained and stored in compliance with regulation.

Facility does not handle residents P&I monies.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 Personnel Report
LIC308 Designation of Responsibility
Liability Insurance

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.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/17/2025 05:42 PM - It Cannot Be Edited

Created By: Ethel Contreras On 11/17/2025 at 05:14 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CORNERSTONE ASSISTED LIVING	FACILITY NUMBER: 486803484
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(i)(1)(B)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and admin observation , the licensee did not comply with the section cited above in that auditory signal system alarm was not loud enough to summon staff. In additon, door signal system in first floor heading toward back parking lot exit next to restrooms was not turned on which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/24/2025
	Plan of Correction
1 2 3 4	Licensee turned on signal system during inspection visit. Submit LIC9098 self certifying that door alarm system will continue to be kept on at all times 24/7 by Plan of Correction due date 11/24/25. In addition, LIC9098 self certifying that batteries will/did get replaced for system to be loud enough to summon staff.

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.

	Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:

	Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

LIC809 (FAS) - (06/04)

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