<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803897
Report Date: 08/27/2021
Date Signed: 08/27/2021 04:07:22 PM

Document Has Been Signed on 08/27/2021 04:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CORNERSTONE RESIDENTIAL, LLC - NOEL'S HOMEFACILITY NUMBER:
486803897
ADMINISTRATOR:NICOLAS, JETHRO & ORTIZ, NFACILITY TYPE:
735
ADDRESS:1621 ARMIJO COURTTELEPHONE:
(650) 745-5080
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 2DATE:
08/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Nina Ortiz, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct a Post Licensing inspection on 8/27/21. LPA conducted risk assessment prior to visit. LPA was greeted by Administrator, Nina Ortiz.

LPA toured the facility and was found to be at a comfortable temperature with all exits free from obstruction. Client's bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were serviced and charged 11/19/2020. Facility smoke detectors and carbon monoxide were found to be functioning properly. Water temperature was tested and measured within regulation of 105-120 degree F. Staff have CPR training and 1st aid certifications. LPA verified that the facility’s medications are kept locked and inaccessible to clients. Toxins are stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available.

LPA went over Inspection Control with Nina Ortiz. Facility will send revised mitigation plan to LPA. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Facility has a 30-day supply of PPE. Facility has a 30-day supply of medication for clients. Facility has conducted staff training on infection control.


No deficiencies issued during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1