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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201140
Report Date: 06/07/2023
Date Signed: 06/07/2023 08:59:44 PM


Document Has Been Signed on 06/07/2023 08:59 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: 4DATE:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Sharon Aranha/AdministratorTIME COMPLETED:
09:00 PM
NARRATIVE
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On this day, June 7, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Gina Tolentino. LPA called and left message on Sharon Aranha's (administrator) voicemail. and informed the reason for visit. LPA also met other staff, Rogelio Tolentino. The administrator arrived after 45 minutes.

Facility has submitted the LIC808 Mitigation Plan but not the LIC9282 Infection Control Plan.

LPA inspected the facility inside and out including but not limited to common areas, bedrooms, bathrooms, living and family rooms, kitchen, dining area, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the ensuite bathrooms was tested, and measured at 109 degrees Fahrenheit. First aid kit was observed complete with manual.

LPA reviewed 4 residents and 5 staff files, and interviewed 2 staff. Medications were checked and compared with records. Facility does not handle residents' cash resources.

LPA observed the following:
-At 11:23 am, Pepto Bismol in the refrigerator.
-At 11:30 am, lancets and Glucose test solution on the desk by the dining area.
-At 11:31 am, fire extinguisher fully charge but tag showed serviced March 12, 2021
-at 11:39 am, wound cleanser and antifungal powder in one of the resident's rooms.
-At 11:44 am, broken toilet paper holder in one of the ensuite bathrooms.
-At 11:46 am, shovel in the backyard.

.......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ASTERA CARE HOME LLC
FACILITY NUMBER: 019201140
VISIT DATE: 06/07/2023
NARRATIVE
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-Facility does not have record of disaster drill being conducted every 3 months. Administrator stated they only watch video, and do not do the actual drill.
-At 3:10 pm, 4 out of 4 staff has not completed the required four hours training specific to postural supports, restricted health conditions, and hospice care
-At 4:45 pm, observed resident (R1) has doctor's order on file for 11 medications, but medications on facility's hand is only 7 of which 2 is not included on the order. Facility does not have the 5 medications on the doctor's order. Medication labels showed filled dates April, May & June 2023 and these were not recorded on LIC622 Centrally Stored Medication and Destruction Record.
-At 5:15 pm, resident (R2) has 3 medications on facility's hand but no doctor's order on file. LIC622 on file is incomplete (no name of resident; quantity of meds received and date started not recorded). R2's bed has half bed rails but no doctor's order on file.
-Resident (R3) has Vitamin and supplements on hand but no doctor's order on file. R3's bed has half bed rails but no doctor's order.
-Resident's (R4) has bed rails but no doctor's order on file. LIC602A Physician's Report showed R4 is dependent on others with all activities of daily living (ADLs).

Administrator to submit the following updated documents by June 21, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan
4. Proof of $3M liability insurance coverage

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: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 06/07/2023 08:59 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: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 above for having a shovel in the backyard, and lancets on the desk by the dining area which pose an immediate safety risks to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Staff locked the items,
In addition, administrator to do in-service training and submit copy of trianing topic with attendees signatures by 6/08/23.
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

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 for Pepto Bismol in the refrigerator, wound cleanser and antifungal powder in one of the resident's rooms, Glucose test solution by the dining area which poses an immediate health and/or personal rights risks to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Staff locked the items,
In addition, administrator to add to in-service training, and submit copy of trianing topic with attendees signatures by 6/08/23
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: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 06/07/2023 08:59 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: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 for broken toilet paper holder in one of the ensuite bathrooms which poses a potential personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Administrator to have the holder fixed or replaced, and submit picture by 6/21/23.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 for not doing the disaster drill which poses a potential safety risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Administrator to conduct drill, and submit proof by 6/21/23.
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: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 06/07/2023 08:59 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: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
87465 Incidental Medical and Dental Care
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 out 3 residents not having complete doctor's order for medications which facility administers. It's not clear whether or not all the medications are needed which pose an immediate health and.or personal rights risks to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Administrator to obtain doctor's orders for all medications. If medications are no longer needed by the residents, to obtain discontinued order(s), Proof to be submitted by 6/08/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 06/07/2023 08:59 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: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
§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.
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 4 out of 4 staff not completing the required 4 hours of postural support, restricted health condiition and hospice care training which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Administrator to have the staff complete the training, and submit copy by 6/21/23.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 3 out 3 residents not having medications properly and completely recorded on LIC622s which pose a potential personal rights risk to persons in care. The quanity of medications received/refilled are also not recorded.
POC Due Date: 06/21/2023
Plan of Correction
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Administrator to complete the LIC622s and self-certify they are done. Self-certification to be submitted by 6/21/23.
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: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 06/07/2023 08:59 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: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions
3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 4 resident's beds having half bed rails but no doctor's orders on file pose a potential safety and/or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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2
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Administrator to obtain doctor's orders, and submit copies by 6/21/23.
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 (ADL) for them as set forth in Section 87459, Functional Capabilities

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 1 out of 4 residents who depends on the staff with ADL which poses a potential health, safety and/or personal rights risk to person in care.
POC Due Date: 06/21/2023
Plan of Correction
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2
3
4
Administrator to submit exception request along with supporting documents including but not limited to LIC602A Physiician's Report, Appraisal/Needs and Services Plan; staff training, letter of support from responsible person.
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: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
LIC809 (FAS) - (06/04)
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