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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803484
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:33:08 AM


Document Has Been Signed on 01/26/2023 11:33 AM - 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: 80DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Shelley ReyesTIME COMPLETED:
11:40 AM
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Licensing Program Analyst Katrina Walters arrived unannounced to conduct an Annual Required Inspection and met with Executive Director, Shelley Reyes.

Upon arrival, LPA observed that there was one central entry point was created for visitors. At the entrance there was a screening station. Visitors are to self screen and have their temperature taken using an application on an Ipad. The application ask a series of questions and automatically takes the visitors temperature.

LPA initiated a tour of the facility with the Administrator and made the following observations: The facility was a comfortable temperature and passageways were free from obstructions. Visitor bathrooms are equipped with paper towels and handsoap. Resident rooms were furnished per regulation with appropriate lighting.

Fire extinguishers were last serviced December 14, 2022. Facility's fire system is maintained by Hue & Cry, Inc. The most recent service of the entire system was conducted January 2023. Smoke and Carbon detectors were tested in resident bedrooms and appeared to be operational. Fire Alarms and Strobes were tested while LPA was present and were functional.

Continued on LIC809C
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/26/2023
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Continued from LIC809

LPA reviewed staff and resident records. Facility keeps copy of vaccine records for residents and staff in their perspective folders. Staff have received training on personal protective equipment (PPE), droplet precautions and education on Monkey Pox. Per Administrator, staff receive training semi-annually. All staff have been fit tested and their results are documented.

Facility has adequate Personal Protective Equipment (PPE) and incontinence products, that is stored in their storage and accessible to staff who need it. In the event that a resident needs to quarantine the facility has isolation carts.


No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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