486803484-6-25-2025-21-AS-VBEI-DJEPZW-20250709114609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803484
Report Date: 06/25/2025
Date Signed: 06/25/2025 02:29:43 PM

Substantiated

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
06/23/2025 and conducted by Evaluator Elias Magdaleno

COMPLAINT CONTROL NUMBER: 21-AS-20250623170032

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: 100	DATE:	06/25/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	SHELLEY REYES, Administrator		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to initiate complaint investigation and deliver findings regarding the allegation listed above and met with Shelley Reyes, Administrator.

During visit LPA observed that facilities A/C unit that controls southern corridor, dining room, and activity room is not functional. Interviews with staff and Administrator indicate that A/C has been broken for a few months and had intermittent functionality summer of 2024. According to Administrator, licensee purchased a new unit a few weeks ago, however, it was the wrong unit. During visit, Administrator received email correspondence that the correct unit will be installed July 1st. Based upon the observations and interviews, there is preponderance of evidence to prove that the allegation(s) have/has been SUBSTANTIATED and are/is valid.
Deficiency cited on LIC9099-D, per Title 22 Regulations, Division 6.
Exit interview conducted. Appeal rights given. Copy of report discussed and provided to Administrator whose signature on form confirms receipt of document(s).

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025

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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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
06/23/2025 and conducted by Evaluator Elias Magdaleno

COMPLAINT CONTROL NUMBER: 21-AS-20250623170032

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: 100	DATE:	06/25/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	SHELLEY REYES, Administrator		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Licensee is not ensuring a comfortable temperature for residents is being maintained at all times.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to initiate complaint investigation and deliver findings regarding the allegation listed above and met with Shelley Reyes, Administrator.

During this investigation, LPA made observations and conducted interviews. LPA observed thermostats read at 74-, 79-, 75-, and 71-degrees F which is within Title 22 regulations of 68 degrees F to 85 degrees F. Outside temperature at time of visit was 82 degrees F. Non-functional A/C affected activity room the most with resident interviews and LPA observations showing that it was warmer then the rest of the facility, actual temperature unknown as thermostat was not functional. However, resident interviews also showed that residents do not feel uncomfortable in the activity room and facility has placed fans to keep temperatures in control. Each resident apartment has a personal A/C unit that allows residents to maintain preferred temperatures in their rooms. Based upon observations and interviews, we have found that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations/complaint is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025

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-20250623170032

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/03/2025 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a). The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors	1 2 3 4 5 6 7	Licensee to submit plan on how they will ensure resident safety from heat in areas affected by non-functional A/C by POC due date of 7/3/2025. Additionally, Licensee shall submit self-certification to CCL of functional A/C when new unit has been installed.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by A/C was observed non-functional resulting in increased temperatures within parts of facility. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Elias Magdaleno
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025

LIC9099 (FAS) - (06/04)

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