486803484-12-22-2022-21-AS-CMAZ-CMJR9P-20221228114948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803484
Report Date: 12/22/2022
Date Signed: 12/22/2022 05:35:16 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
09/12/2022 and conducted by Evaluator Katrina Walters

COMPLAINT CONTROL NUMBER: 21-AS-20220912123502

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: 79	DATE:	12/22/2022
		UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	Shelley Reyes		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Resident fell and sustained an injury due to building and grounds.
Staff did not seek timely medical attention for resident in care.
Staff did not maintain resident's records accurately.
Staff dId not adequately supervise resident in care.

INVESTIGATION FINDINGS:

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On this date Licensing Program Analyst (LPA) Katrina Walters arrived unannounced for the purpose of delivering the findings for this complaint, regarding the above-mentioned allegations, and met with Administrator, Shelley Reyes.

The Santa Rosa Community Care Licensing Regional Office received a complaint on 09/12/2022 alleging: Resident sustained an injury due to an unwitnessed fall, Staff did not seek timely medical attention for resident in care, Staff did not maintain resident's records accurately and Staff did not adequately supervise resident in care. An intial visit to open the complaint was conducted on 9/13/22, and subsequent visits occured on 11/02/22 and today,12/22/22 to gather additional information and deliver complaint findings.

Continued on 9099 C

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: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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 4

Control Number 21-AS-20220912123502

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: 12/22/2022

NARRATIVE

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During the course of this investigation, LPA reviewed the following records regarding R1: Needs and Service Assessment, Care plan, Charting notes, Emergency Information Admission Agreement, Physician Report. In addition to reviewing residents documentation, LPA made observations and conducted interviews with staff and responsible parties.

Based on the interviews, records, and observations made during the investigation the following determinations were made:The first allegation alleged- Resident (R1) fell and sustained an injury due to building and grounds. More specifically that R1 fell due to an uneven surface. LPA conducted a tour and made observations of the buildings and grounds. (picture taken) Based on interviews and LPA's observation it was determined that the grounds and floors were adequately maintained and not a safety risk for residents in care.

The second allegation alleged- Staff did not seek timely medical attention for resident R1 in care. Based on interviews, and records LPA learned after R1 sustained an injury on 5/26/2022. There were conflicting statements on whether they sought assistance from their responsible party after or prior to informing the facility that they had a fall and needed medical attention, however it was determined that the responsible party would transport them to a medical facility. According to interviews R1 did not appear or state they required immediate medical attention. Interviews and R1's 602 physician report indicate that R1 is able to communicate their own needs and are responsible for their own treatment. Interviews also reveled that R1 indicated that it was not necessary that they be transported by EMTs.

Continued onto 9099 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20220912123502

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: 12/22/2022

NARRATIVE

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The third allegation alleged staff did not adequately supervise resident in care. LPA conducted interviews and reviewed resident R1's records which including their needs and service appraisal and physician report and it was determined that R1 did not require supervision and can manage their own treatment and care.

The fourth allegation alleged-Staff did not maintain resident's records accurately. LPA reviewed 5 of 5 resident records. Staff were able to provide LPA with 5 of 5 resident records timely. Records were organized and complete.

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: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4