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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803897
Report Date: 11/17/2023
Date Signed: 11/28/2023 01:16:19 PM

Document Has Been Signed on 11/28/2023 01:16 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:NINA ANGEL GERMANFACILITY TYPE:
735
ADDRESS:1621 ARMIJO COURTTELEPHONE:
(650) 745-5080
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 4DATE:
11/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Nina German, AdministratorTIME COMPLETED:
01:00 PM
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On 11/17/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Staff, Agnes Ortiz. Administrator, Nina German and Licensee, Jethro Nicolas were contacted and notified and arrived later in the visit. The facility currently provides care for 4 clients, two of which were attending day program or on outings and two of which were present. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/21/2022. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. The facility staff replenish fresh food supply on a weekly basis. Water at faucets accessible to clients was measured at 112.4 degrees F which is within Title 22 Regulations.

LPA continued with a tour of the backyard and outside parameters and found emergency exit along the sides of the home to be unobstructed. One shed located in the backyard for additional storage was found to be secured. The facility was approved by North Bay Regional Center for funding for a new outdoor deck space for client use. The construction plans have been approved by the city with expected completion within the next several weeks. The deck space will provide a more adequate outdoor leisure that accommodates non-ambulatory status clients. Medications are stored in a designated lockbox containers located in the kitchen area and found to be secured. A spot medication count was conducted for clients and found to be in order. The facility is provided Medication Administration Records, from the pharmacy and includes prescription numbers, administration orders and start times all of which were in order. Knifes, cleaning supplies and other items that could be potentially dangerous if accessible to residents were all secured and inaccessible.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
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: 11/17/2023
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Staff were observed to have a positive relationship with clients. The clients are offered various activities including shopping, walking around the neighborhood and visiting parks and other public group outings. Clients were observed interacting and watching television with staff, in their rooms participating in independent activities such as crochet or coloring for leisure. Upon a review of client records, LPA found all files including physician's reports and individual program plans to be in order. A review of all client P&I monies was conducted and found to be in order with no funds commingled. Upon a review of staff records, LPA found all staff to have adequate annual training and 1st Aid & CPR certification on file. LPA reviewed current Guardian staff roster and found all staff to be properly associated to the facility.

The facility has been approved by R&D Transportation Services and provides direct transport for clients to and from their respective day programs. LPA observed the facility vans to be properly equipped with a first aid kit and fire extinguisher with maintenance conducted on a quarterly basis. Emergency disaster drills are also conducted with all clients on a monthly basis with Emergency Disaster Plan updated and on file.

Administrator, Nina German's Administrator Certification 6050389735 is currently valid through 3/7/2024.

LPA requested the following documents be sent to CCL by COB 12/17/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership
Updated Facility Sketch indicating emergency exits

No deficiencies cited.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
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