486803484-7-6-2023-21-AS-KMOA-CU4TLW-20230726145013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803484
Report Date: 07/06/2023
Date Signed: 07/06/2023 04:42:52 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
03/29/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20230329092303

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: 88	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	03:38 PM
MET WITH:	Shelley Reyes, Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff do not prevent a resident from causing harm to other residents while in care

INVESTIGATION FINDINGS:

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On 7/6/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Shelley Reyes. LPA, interviewed staff, reviewed resident records and made observations during the course of the investigation.

Complaint alleges staff do not prevent a resident (R1) from causing harm to other residents while in care. Upon review of R1’s Physician’s Report and Pre-Admission Appraisal, there was no indication of aggressive or combative behaviors upon admission. Based on a review of daily progress notes for resident (R1), LPA found that several months after R1’s admission to the facility, R1 began showing behaviors of inappropriate verbal comments towards staff. R1’s behaviors progressively became more frequent and had been observed in common areas open to other residents. The facility had recorded and reported to CCLD of several incidents in which R1 had become verbally and physically aggressive, leading to an incident in which R1 had been observed yelling and breaking dishware in the dining area. However, based on a review of incident reports; and interviews with the Executive Director and Care Cooridinator (S1), there were no indications of R1 causing physical harm or hurting another residents in care. Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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-20230329092303

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: 07/06/2023

NARRATIVE

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Based on interviews with Executive Director, LPA found that an updated care plan was implemented to mediate R1’s behaviors. In addition, LPA interviewed Care Coordinator (S1) who indicated that on multiple occasions; the facility had notified and spoken with R1’s responsible party, attempting to find a more a appropriate level of care for R1 as staff observed R1's behaviors more frequently. S1 also stated that they assisted R1's responsible party with identifying several alternate living options for R1. Lastly, the facility had come to an agreement with R1's family and submitted a legal eviction notice for R1 on 4/20/2023 to reinsure R1 was placed at a higher level of care.

The facility and staff were aware of R1’s changes of behavior and attempted multiple interventions to address concerns ultimately leading to R1 being transferred to a higher level of care. Due to a lack of corroborating evidence the allegation, staff do not prevent a resident from causing harm to other residents while in care is found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited. Appeal Rights given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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