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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803484
Report Date: 07/15/2025
Date Signed: 07/15/2025 02:16:52 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
04/25/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250425105956
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: 103DATE:
07/15/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shelley Reyes, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not dispense medications as prescribed
INVESTIGATION FINDINGS:
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On 07/15/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250425105956 investigation findings regarding the above allegation and met with Shelley Reyes, Administrator. Reporting Party (RP) alleges that the facility staff did not dispense medications as prescribed for Resident 1 (R1).

LPA Florio conducted a 10-day complaint investigation visit on 04/28/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through R1’s Centrally Stored Medication Record and an interview with Staff 1 (S1) that the facility received R1’s medications on 04/20/2025. S1 stated that the prescription “said to hold the medication if the blood pressure was at a certain level, but we did not have an order to check a daily blood pressure.” S1 attempted to reach the physician to obtain a separate order for blood pressure monitoring and was unsuccessful.

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

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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 3
Control Number 21-AS-20250425105956
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: 07/15/2025
NARRATIVE
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Continued from LIC9099...

S1 then left a note for Staff 2 (S2) to follow up with R1’s physician. There are no records of S2 following up. S1 stated that medication was held until orders could be obtained.

On 5/28/2025, an interview with R1’s treating physician revealed that R1 was in stage four terminal heart failure and had pneumonia. Additionally, the physician stated that they did not believe that the medications in question would have changed R1’s terminal prognosis.

However, during today’s complaint investigation visit, an interview with Staff 3 (S3) revealed that no log was maintained showing staff observed R1 for swelling or other symptoms of fluid retention. Based on interviews and record review, the facility was unable to provide proof that staff followed through with obtaining blood pressure parameter orders or that staff dispensed medications as prescribed, (see LIC9099D).

Based on interviews conducted and records obtained, the allegation that the facility staff did not dispense medications as prescribed is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250425105956
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: 07/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2025
Section Cited
CCR
87465(a)4
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Incidental Medical and Dental Care 87465(a)4 The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Administrator to submit scheduled training date with a self-certification to CCLD by POC date 07/16/2025.
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Based on interviews and records review, facility did not dispense R1's medications as prescribed. This poses an immediate health, safety, and/or personal rights risk to residents in care.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3