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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201140
Report Date: 06/21/2024
Date Signed: 06/21/2024 06:47:51 PM


Document Has Been Signed on 06/21/2024 06:47 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:ASTERA CARE HOME LLCFACILITY NUMBER:
019201140
ADMINISTRATOR:ARANHA, SHARONFACILITY TYPE:
740
ADDRESS:1528 SEAVER CTTELEPHONE:
(510) 200-5922
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY:6CENSUS: 6DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Sharon Aranha/Administrator TIME COMPLETED:
06:50 PM
NARRATIVE
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On this day, June 21, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Aaron Salvador. LPA called and spoke over the phone with Sharon Aranha, administrator, and informed the reason for visit. LPA also met with other staff, Mark Kevin Salvador. Administrator arrived at 12:29 p.m.

Facility has submitted the LIC808 Mitigation Plan but not the LIC9282 Infection Control Plan. LPA requested for LIC9282 on June 23, 2023 which LPA has not received up to this day.

LPA inspected the facility inside and out with Mark Kevin Salvador, LPA inspected the kitchen, dining room, living and family rooms, bedrooms, bathrooms, garage, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Facility has smoke and carbon monoxide detectors that were checked and observed in operating condition. Hot water temperature in the ensuite bathroom was tested. Facility conducts drills every quarter and records showed fire drill last conducted 5/01/24.

LPA reviewed 5 residents and 4 staff files, and interviewed 2 staff and 2 residents. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.

LPA observed the following:
-at 11:57 a.m., hot water was at 124 degrees Fahrenheit.
-at 11:58 a.m., Ca-Rezz incontinent wash in one of the residents' rooms.
-at 12:03 p.m., razor in the cabinet in the common bathroom.
-at 12:06 p.m., Ca-Rezz continent wash and ointment in another resident's room.

.....continued on 809C (page 2)
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ASTERA CARE HOME LLC
FACILITY NUMBER: 019201140
VISIT DATE: 06/21/2024
NARRATIVE
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Page 2

-at 12:45 pm.m, trash cans in 2 residents rooms without lids.
-at 2:00 pm to 2:35 p.m., staff (S2, S3, S4) who were hired 10/18/23 have only total 21 hours of training on file and no medication training.
-at 3:30 p.m. to 4:00 p.m, , residents (R1, R2, R3, R4 and R5) have no Pre-admission Appraisal on file.
R4's LIC602A Physician's Report indicated R4 needs assistance with all activities of daily living (ADLs); however, LPA observed R4 feeding self during lunch.
R5's LIC602A Physician's Report indicated R5 needs assistance on with all ADLs.

LPA received a copy of $3M Liability Insurance certificate on this day.

Administrator to submit copies of the following updated documents by July 5, 2024:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2024 06:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ASTERA CARE HOME LLC
FACILITY NUMBER: 019201140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 in hot water at 124 degrees Fahrenheit which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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2
3
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Administrator to have the temperature adjusted within Regulations range and submiit proof by 6/21/24,
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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2
3
4
Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risks to persons in care: unlocked Ca-Rezz; ointment; razor
POC Due Date: 06/21/2024
Plan of Correction
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Staff locked the items
In addition, adminsitrator to do in-service training and submit copy of training topic with attendees signatures by 6/21/24
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 06/21/2024 06:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ASTERA CARE HOME LLC
FACILITY NUMBER: 019201140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

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 in trash cans without lids in residents' rooms which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
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Administrator to purchase trash cans with foot pedal operated lid and submit proof of purchase and picture by 7/05/24.
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
§1569.625 Staff training; legislative findings; contents
(b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview of staff and records review, the licensee did not comply with the section cited above in S2, S3 and S4 not having the required 40 hours of training which pose a potential health, safety and/or personal rights risks to persons in care. Staff only have total 21 hours of training on file.
POC Due Date: 07/05/2024
Plan of Correction
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Administrator to have the 3 staff complete the required training and submit proof by 7/05/24.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 06/21/2024 06:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ASTERA CARE HOME LLC
FACILITY NUMBER: 019201140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and records review, the licensee did not comply with the section cited above in S2, S3 and S4 not having medication training on file which pose a potential health and/or personal rights risks to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
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Administrator to have the 3 staff complete the training and submit proof by 7/05/24.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents not having Pre-admission Appraisal which poses a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
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Administrator to do the Pre-admission and submit self-certication indicating documents are completed.
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 06/21/2024 06:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ASTERA CARE HOME LLC
FACILITY NUMBER: 019201140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records rreview, the licensee did not comply with the section cited above in 5 out of 5 residents not having LIC9172 Functional Capability Assessment on file which pose a potential health, safety and/or personal rights risks to persons in care.
POC Due Date: 07/05/2024
Plan of Correction
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2
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Adiministrator to complete the LIC9172s and submit self-certification by 7/05/24,
Type B
Section Cited
CCR
87458(c)
87458 Medical Assessment
(c) The licensee shall obtain an updated medical assessment when required by the Department.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in R4's LIC602 not consistent with R4's current condition of able to feed self which poses a potential personal rights risk to person in care.
POC Due Date: 07/05/2024
Plan of Correction
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2
3
4
Administrator to have the LIC602A updated and submit copy by 7/05/24,
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 06/21/2024 06:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: ASTERA CARE HOME LLC
FACILITY NUMBER: 019201140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87615(a)(5)
87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, record review and interviiew of staff, the licensee did not comply with the section cited above in retaining R5 who is dependent on staff with all ADLs which poses a potential health, safety andor personal rights risk to person in care.
POC Due Date: 07/05/2024
Plan of Correction
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2
3
4
Administrator stated she'll submit exception request. Request letter to be submitted along with the following by 7/05/24:
1. LIC602A Physician's Report 2. LIC625 Appraisal/.Needs and Services Plan
3. LIC9172 functional Capabilty Assessment 4. . Proof of staff training.
5. Letter from resident's responsible person supporting R5's stay in the facility
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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