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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803897
Report Date: 02/28/2022
Date Signed: 02/28/2022 01:36:57 PM

Document Has Been Signed on 02/28/2022 01:36 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: DATE:
02/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Jethro NicolasTIME COMPLETED:
01:46 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 Analysts (LPAs) Willis and Felias arrived unannounced to conduct a Case Management visit regarding a special incident report.

LPAs spoke with Administrator, Jethro Nicolas. Per Administrator, client, C1 was admitted to the facility on October 1, 2021 and was on a mechanical soft, thin liquids diet. C1 had a choking incident and was sent to the hospital on December 19, 2021. Client underwent a swallow evaluation on December 28, 2021 and was discharged from hospital on December 29, 2021 with additional guidance regarding diet. C1 had a second incident on February 9, 2022. While eating breakfast with staff assistance, C1 started coughing and became restless. Staff heard a gurgling sound from C1's throat and chest and staff noticed labored breathing. Per conversation with Administrator, the doctor believes the client aspirated while drinking water. Per Administrator, staff was alternating between food and liquids per the diet plan.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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