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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601380
Report Date: 03/09/2022
Date Signed: 03/10/2022 04:00:57 PM

Document Has Been Signed on 03/10/2022 04:00 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ALLSTAR RESIDENCEFACILITY NUMBER:
015601380
ADMINISTRATOR:BASA, JUDYFACILITY TYPE:
740
ADDRESS:7875 IRONWOOD DRIVETELEPHONE:
(925) 875-1737
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Judy Taloma-BasaTIME COMPLETED:
02:45 PM
NARRATIVE
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On 03/09/22 at 11: 13 am Licensing Program Analysts (LPA) J. Clancy-Czuleger and K. Nguyen arrived unannounced to conduct infection control inspection LPAs meet with Judy Taloma-Basa and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. The facility has a mitigation plan.

The following deficiency was observed during the visit:


Water temperature was measured at 125.1 F.
Chemicals were out and accessible to residents
Staff 1 did not have finger print clearance
Staff 2 was not associated to the facility

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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 3
Document Has Been Signed on 03/10/2022 04:00 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 03/09/2022 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ALLSTAR RESIDENCE
FACILITY NUMBER: 015601380

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, water tempature was measured at 125.1 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2022
Plan of Correction
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By POC date licensee will submit photo proof that the water heater was adjusted so the water is between 105 and 120 degrees
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having laundry detergent and chemical cleaners accessible in a bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2022
Plan of Correction
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By POC date licensee will submit photo proof that the chemicals have been relocated to a lcoked cabinet.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 03/10/2022 04:00 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 03/09/2022 at 02:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ALLSTAR RESIDENCE
FACILITY NUMBER: 015601380

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview record review, the licensee did not comply with the section cited above in one count, by having a staff member who not have fingerprints or background check which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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Staff was removed from the facility and civil penalty was administered
Type A
Section Cited
CCR
87355(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one count by having a staff member who was not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2022
Plan of Correction
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Licensee resubmited transfer paperwork durring inspection
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022


LIC809 (FAS) - (06/04)
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