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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803484
Report Date: 04/28/2025
Date Signed: 04/28/2025 01:39:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
01/27/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250127085410
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: 97DATE:
04/28/2025
UNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Shelley Reyes, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff not ensuring contaminated surfaces are disinfected
Facility staff not addressing change in resident’s condition
INVESTIGATION FINDINGS:
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On 04/28/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250127085410 investigation findings regarding the above allegations and met with Shelley Reyes, Administrator. Reporting Party (RP) alleges that the facility is not addressing changes in Resident 1 (R1’s) condition and that facility is not ensuring contaminated surfaces are disinfected which RP says have resulted in odors in the facility and visibly soiled furniture within the facility.

LPAs Florio and Stevenson conducted 10-day complaint investigation visit on 01/28/2025 and obtained documents, made observations, and conducted interviews with Staff (S1) and Staff 2 (S2). Based on LPA’s interviews, observations made, and documents obtained, LPA received conflicting information regarding the above allegations. During 01/28/2025 facility visit, LPA toured the facility, and no odors were present nor where any surfaces observed soiled during the inspection.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
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 2
Control Number 21-AS-20250127085410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CORNERSTONE ASSISTED LIVING
FACILITY NUMBER: 486803484
VISIT DATE: 04/28/2025
NARRATIVE
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Continued from LIC9099...

LPA was informed that the facility activities director wipes down all chairs and surfaces in the activities area regularly, the facility has the cleaning crew clean the carpets every Friday, and the facility has a carpet cleaner/extractor on site that they use to clean up any visibly soiled areas immediately. LPA received copies of R1’s pre-placement appraisal and care plan documentation from Licensee which confirm that R1 has a known, documented history of lymphedema and has been receiving home care to wrap their legs three times per week since being admitted to the facility 06/2024. Additionally, based on documentation and shower logs received, facility staff offer R1 bathing assistance two times per week, but R1 often refuses. Lastly, on 4/23/2025, LPA obtained a staff roster showing sufficient staffing, and LPA spoke with facility administrator who informed LPA that R1 relocated to a new facility that offers memory care.

Based on record review, interviews conducted, and observations made, the allegations that the facility is not addressing changes in Resident 1 (R1’s) condition and that facility is not ensuring contaminated surfaces are disinfected are UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2