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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803897
Report Date: 04/11/2023
Date Signed: 04/11/2023 08:51:56 AM

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
03/02/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20230302144135
FACILITY NAME:CORNERSTONE RESIDENTIAL, LLC - NOEL'S HOMEFACILITY NUMBER:
486803897
ADMINISTRATOR:NINA ANGEL GERMANFACILITY TYPE:
735
ADDRESS:1621 ARMIJO COURTTELEPHONE:
(650) 745-5080
CITY:FAIRFIELDSTATE: ZIP CODE:
94534
CAPACITY:4CENSUS: 3DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Caregiver, Neal OrtizTIME COMPLETED:
09:10 AM
ALLEGATION(S):
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Staff violated clients personal rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Cornerstone Residential, LLC-Noel's Home for the purpose of delivering complaint findings. LPA was greeted at the door by Caregiver, Neal Ortiz, and was granted access into the facility.

During the course of the investigation, LPA reviewed resident records, facility records, interviewed staff, clients in care, a witness and an outside provider.

Complaint alleges Staff violated client’s personal rights. Based off of records reviewed and interviews that were conducted, LPA could not prove or disprove the allegation. Furthermore, LPA interviewed outside providers and witnesses who could not corroborate the allegation. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
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-20230302144135
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 RESIDENTIAL, LLC - NOEL'S HOME
FACILITY NUMBER: 486803897
VISIT DATE: 04/11/2023
NARRATIVE
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A finding that the complaint allegations of Staff violated client’s personal rights is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Caregiver.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2