486803484-12-17-2021-21-AS-CMAZ-CACNLB-20220104093317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803484
Report Date: 12/17/2021
Date Signed: 12/17/2021 10:26:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20211020122525

FACILITY NAME:	CORNERSTONE ASSISTED LIVING		FACILITY NUMBER:	486803484
ADMINISTRATOR:	SHELLEY REYES		FACILITY TYPE:	740
ADDRESS:	40 ORANGE TREE CIRCLE		TELEPHONE:	(707) 592-1157
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	130	CENSUS: 86	DATE:	12/17/2021
		UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Administrator, Shelley Reyes		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility is understaffed.
Lack of supervision resulting in resident(s) falls.
Resident(s) are wandering from the facility.
Resident(s) are sustaining injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Cornerstone Assisted Living for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Shelley Reyes and was granted access into the facility.

During the course of the complaint investigation, LPA interviewed staff, residents, reviewed staff, client and facility records.

Complaint alleges that facility is understaffed. Based on record review, LPA learned that the Staff Roster appeared to be appropriate at the time of the review. In addition, an unannounced subsequent complaint inspection investigation was conducted on November 22, 2021. During the tour of the facility, LPA observed sufficient amount of staff members present at the facility.

(Report continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20211020122525

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CORNERSTONE ASSISTED LIVING	FACILITY NUMBER: 486803484
	VISIT DATE: 12/17/2021

NARRATIVE

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Complaint alleges that there is a lack of supervision resulting in resident(s) falls, resident(s) sustaining injuries while in care and residents wandering from the facility. Based on LPA interviews and record review, LPA learned that there was an unwitnessed fall that occurred at the facility regarding Resident #1 (R1) which resulted in injuries. Facility reported this unwitnessed fall in a timely fashion to Community Care Licensing and the Responsible Party was notified. During interviews, LPA learned that R1 slipped and fell which led to R1 sustaining injuries and that the facility did everything that they could have done to take care of the resident. In addition, it was disclosed that R1 did not leave the facility unassisted at any point in time during R1’s residency at the facility, and that R1 used to take walks in front of the facility, but never left the facility unassisted. Additional interviews were conducted with a random sample of residents and those interviews yielded no concerns. LPA observed residents in care to be content and happy in placement.

Based on the interviews that were conducted, the observation of the facility and the documents/evidence reviewed, the allegations of, facility is understaffed, lack of supervision resulting in resident(s) falls, resident(s) sustaining injuries while in care and residents wandering from the facility will be Unsubstantiated. A finding that the complaint allegation is unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was signed and emailed to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

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