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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803484
Report Date: 03/04/2022
Date Signed: 03/04/2022 05:52:18 PM


Document Has Been Signed on 03/04/2022 05:52 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: 90DATE:
03/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:39 PM
MET WITH:Aida Reye SantosTIME COMPLETED:
06:05 PM
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Licensing Program Analyst (LPA) Walters arrived unannounced and was greeted by Assistant Administrator, Aida Rea Santos (ARS). The Administrator was not present for this visit, but was availably by phone. The purpose of this visit is to follow up on a self reported incident that occurred on 1/24/22 involving staff (S1) and Resident (R1). It was alleged that S1 was observed yelling at R1. LPA interviewed Resident's (R1) and (R2). SR conducted an investigation of the incident, and based on the results S1 was terminated.

This incident will require further investigation. No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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