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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803897
Report Date: 12/01/2025
Date Signed: 12/01/2025 12:20:47 PM

Document Has Been Signed on 12/01/2025 12:20 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CORNERSTONE RESIDENTIAL, LLC - NOEL'S HOMEFACILITY NUMBER:
486803897
ADMINISTRATOR/
DIRECTOR:		NINA ANGEL GERMANFACILITY TYPE:
735
ADDRESS:1621 ARMIJO COURTTELEPHONE:
(650) 745-5080
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 3DATE:
12/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:27 AM
MET WITH:Administrator, Nina Angel GermanTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 12/01/2025, Licensing Program Analyst (LPA) Ali Deniz conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Administrator, Nina German and Licensee, Jethro Nicolas arrived later in the visit. The facility currently provides care for 3 clients, one of which were attending day program or on outings and two of which were present. LPA was informed that there were 3 staff members on-site.

LPA reviewed current Guardian staff roster and found all staff to be properly associated to the facility.

LPA continued with a tour of the facility with administrator. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 02/13/2025. 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. Knifes, cleaning supplies and other items that could be potentially dangerous if accessible to residents were all secured and inaccessible. Water at faucets accessible to clients was measured at 108.6 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 has a new outdoor deck space for client use. The deck space provides a more adequate outdoor leisure that accommodates non-ambulatory status clients. Medications are stored in a designated lockbox container located in the kitchen area and found to be secured. A spot medication count was conducted for clients and found to be in order.

Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CORNERSTONE RESIDENTIAL, LLC - NOEL'S HOME
FACILITY NUMBER: 486803897
VISIT DATE: 12/01/2025
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Continued from LIC809...

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. 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.

At approximately 11:00AM, LPA reviewed 3 resident records and found all residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contained physician's orders for each resident.


At approximately 11:30AM, LPA reviewed 3 staff records. 3 of 3 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1st Aid certifications.

A review of all client P&I monies was conducted and found to be in order with no funds commingled. 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 7017775735 is currently valid through 03/07/2026.

LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 09/28/2025.



Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 12/15/2025:

LIC 308 Designation of Facility Responsibilities
LIC 610 Emergency Disaster Plan (If Changed)
LIC 9020 Register of Facility Client’s/Resident’s
Copy/Proof of Updated Certificate of Liability Insurance

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.
Exit interview conducted. Copy of report provided to Administrator. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025
LIC809 (FAS) - (06/04)
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