486803484-8-26-2022-21-AS-CMAZ-CL6NAS-20221114091802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803484
Report Date: 08/26/2022
Date Signed: 08/26/2022 03:50:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/13/2022 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220613094113

FACILITY NAME:	CORNERSTONE ASSISTED LIVING		FACILITY NUMBER:	486803484
ADMINISTRATOR:	SHELLEY REYES		FACILITY TYPE:	740
ADDRESS:	40 ORANGE TREE CIRCLE		TELEPHONE:	(707) 999-5029
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	130	CENSUS: 87	DATE:	08/26/2022
		UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Shelley Reyes, Administrator		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Facility is in disrepair
Staff does not provide a safe environment for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Walters arrived unannounced to deliver findings regarding the above allegations and met with Facility Administrator, Shelley Reyes.

During the course of this investigation LPA made observations, reviewed records, reviewed security footage, conducted interviews with staff, and Administrator. The following determinations were made:

Continued on LIC 9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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-20220613094113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 LIVING	FACILITY NUMBER: 486803484
	VISIT DATE: 08/26/2022

NARRATIVE

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***This document has been amended*** Administrator was not present to sign amended document. Amended report signed by Outreach Marketing Director, Kendra Bailey.*******

It was alleged that the facility was in disrepair which resulted in the residents not having a safe environment. More specifically, that the facility door was in disrepair which posed a risk to residents, of them exiting and others entering the facility. LPA conducted two visits to the facility and observed that the door's automatic/sensor feature did not allow the door to open automatically. Staff demonstrated for LPA that the doors could be closed and opened manually by staff. A sign on the front of the facility door requested that the visitors ring the door bell for staff to open the entrance doors. In the event of an emergency staff also demonstrated that the doors could be opened for the residents safety. LPA also reviewed documentation from an emergency door repair person, that advised that the sensors not be used until the repairs are made. Per documentation, the facility placed an initial request for repair on 5/25/22 but per statements from staff they were waiting for parts. Statements from staff also indicate that after the receptionist left, doors were closed manually, and were not left ajar and that the doors did not pose a safety hazard for residents. Administrator provided LPA with documentation that the repairs have been made. There wasn't sufficient information to prove that the allegations: Facility is in disrepair and Staff does not provide a safe environment for residents occurred. Therefore the complaint is Unsubstantiated.

A finding that the complaint allegation is unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.

No deficiencies cited.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

LIC9099 (FAS) - (06/04)

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