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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803897
Report Date: 12/20/2022
Date Signed: 12/20/2022 01:01:05 PM

Document Has Been Signed on 12/20/2022 01:01 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: 4DATE:
12/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator, Jethro NicolasTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Cornerstone Residential, LLC-Noel's Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, Jethro Nicolas, and was granted access into the facility.

LPA toured the facility with the Administrator, and observed that the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on December 2021 at the time of the inspection with the expected service/new Fire Extinguisher today, December 20, 2022. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. First aid kit was inspected and found to be appropriate during the inspection. Water temperature in resident's bathrooms measured at 116 degrees in 3 of 3 clients bathrooms which is an acceptable range of 105-120 degrees. There was sufficient perishable and non-perishable foods located in the kitchen. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located under the kitchen sink and in the laundry room that was locked and inaccessible to clients in care. There was a supply of cleaners, hygiene products and paper products available for clients. All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. Last Emergency Disaster drill conducted in December 13, 2022.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE which is stored in the hallway closet. Staff have been PPE trained. Facility staff have not been N95 Fit tested (See LIC 9102)

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/20/2022
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LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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