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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607901
Report Date: 08/24/2023
Date Signed: 08/24/2023 03:57:34 PM


Document Has Been Signed on 08/24/2023 03:57 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:STARLIGHT CARE HOMEFACILITY NUMBER:
197607901
ADMINISTRATOR:ANA F. DUENASFACILITY TYPE:
740
ADDRESS:1704 KERRY COURTTELEPHONE:
(626) 810-4104
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY:6CENSUS: 4DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ana Duenas, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Galarza Nune Margaryan conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Ana Duenas. There are currently 4 elderly residents 60 years and older residing in the facility. One (1) resident is receiving hospice care, one (1) resident receives home health, one (1) resident has Dementia, and one (1) resident is bedridden. The inspection was completed using the CARE tools. Twelve (12) CARE tools domains were reviewed.

Infection Control:

  • Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer screened for COVID-19 or required to sign in. The facility submitted a COVID-19 Mitigation Plan, but an Infection Control Plan has not been submitted.


Operational Requirements:
  • A current Plan of Operation was reviewed.
  • The facility has a Dementia Waiver in place. A Hospice Waiver for 3 is approved.
  • A fire clearance for 5 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 4 only.
  • Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is expired. Licensee/Administrator has not renewed the policy in several years.
  • A surety bond is not applicable. Facility does not handle resident's money.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
VISIT DATE: 08/24/2023
NARRATIVE
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Physical Plant/Environment Safety:
  • The facility is a single story home located in a residential neighborhood consisting of 4 resident bedrooms (2 shared and 1 private), 2 bathrooms, living room, dining room, kitchen, outdoor covered patio area, and 2 car attached garage with laundry area. Resident room # 3 is presently being used as a live-in staff room for staff (S2), and staff (S3) sleeps in the living at night.
  • The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Kitchen drawers containing knives/sharp objects were unlocked, and scissors were observed unlocked in the living room and kitchen. Citation was issued.
  • The facility has three (3) fully charged fire extinguisher and fire sprinklers.
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 101.6 - 109.9 degrees Fahrenheit.

Staffing:
  • A total of 2 caregiver staff provide care and supervision to the clients.

Personnel Records/Staff Training:
  • Administrator certificate expired 7/26/2021. Licensee/Administrator submitted proof of training to certification unit and is awaiting receipt of current certificate.
  • Personnel files were reviewed. They were missing current staff training and staff (S1 & S2) did not have 1st Aid/CPR training on file. The last documented training for staff (S2 & S3) was in 2018.

Resident Records/Incident Reports:
  • A total of two (2) resident files were reviewed. Residents (R1 & R3) did not have any files. Administrator stated residents have not been appraised and required documents have not been obtained from resident responsible parties. Dementia resident (R2's) Physician Report is not updated. Licensee/Administrator shall ensure residents are appraised and there is record of all required documents as soon as they move in. Missing documents are admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, Functional Capability Assessment, and emergency information.
  • RCFE complaint poster and Personal rights were observed posted in the facility entrance area.

***narrative continues next page***
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
VISIT DATE: 08/24/2023
NARRATIVE
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Planned Activities:
  • Sufficient space to accommodate both indoor and outdoor activities was observed. Minimal indoor and outdoor activities are performed.
  • The facility does not have a Resident Council.

Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. However, expired food cans and damaged food cans were observed in the kitchen pantry. Citation was issued.
  • Physician orders for modified diets are in place.

Incident Medical and Dental:
  • 30-day supply of resident medications were observed. No Centrally Stored Records for medications are kept. Citation was issued.
  • Medication error was observed in resident (R2's) bubble pack. Controlled subtance Hydrocodone 325 mg is supposed to be administered 3 times a day, but it is given as a PRN. Citation was issued.
  • Medical and dental transportation is provided by family members and Administrator.

Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610E is in place and was posted today.
  • The last emergency disaster drill was conducted in late 2019. Citation was issued.

Residents with Special Health Needs:
  • One (1) resident receives hospice care and one (1) resident received home health services. Hospice Care Plan was reviewed.
  • Postural supports are used by one resident. No physician orders are on file.
  • Full and half bed rails for mobility assistance were observed in resident beds.
  • No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.
Exit interview was conducted with Administrator Ana Duenas. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
Personal Accommodations and Services.
Living accommodations and grounds shall be related to the facility's function. The facility .... provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, the licensee did not comply with the section cited above in that LPA observed live-in staff (S2) sleeps in resident room # 3 which is designated as a resident room. In addition, llive- in staff (S3) sleeps in the living room and has their belongings in the garage; which poses/posed a potential health, safety or personal rights risk to persons in care. Pictures were taken.
POC Due Date: 09/14/2023
Plan of Correction
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Licensee shall submit a written plan of correction stating how the citation will be corrected. For example, if licensee would like to convert room #3 into a live-in staff room, then the Plan of Operation, and facility sketch must be updated. NOTE: The plan of operation and facility sketch do not state resident room #3 is designated as live-in staff.
Section Cited
Deficient Practice Statement
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2
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POC Due Date:
Plan of Correction
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2
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87506(b)(14)
Resident Records
Each resident’s record shall contain at least the following information: Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services

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 that Licensee/Administrator does not have any centrally stored medication records and/or Medication Administration Records (MAR's) for any of the residents in care. Staff are administering bubble pack medications without physician orders and centrally stored records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator shall ensure centrally stored medication records are kept for all residents in care. Submit proof of centrally stored medication form and/or MAR records provided by resident pharmacies.
Section Cited
Deficient Practice Statement
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2
3
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 that the facility does not have a carbon monoxide detector; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator agreed to submit a picture of the installed carbon monoxide detector by tomorrow.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 that resident medications were observed to be unlocked in the kitchen cabinet and a bubble pack was on top of the dining room table at the beginning of the visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator shall conduct staff training, submit proof that staff were trained by a pharmacy staff and/or RN by tomorrow.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2023 03:57 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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 that kitchen knives/sharps/scissors were unlocked in the kitchen and an additional pair of scissors were observed unlocked in the living room shelf next to incontinence supplies, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Administrator shall submit a written plan of correction, and proof of staff training with staff signatures.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that Administrator has not developed an Infection Control Plan (ICP),which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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2
3
4
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on interview, the licensee did not comply with the section cited above in that Liability Insurance is expired and there is no current policy in place, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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2
3
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Administrator agreed to submit proof of current Liability Insurance in the amount of of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 8 of 11


Document Has Been Signed on 08/24/2023 03:57 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that residents (R3 & R4) do not have admission reports, appraisals, and any files on the residents. Both residents were admitted 8/14/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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2
3
4
Administrator shall submit proof that all resident files have required documents i,e, admission agreements, appraisals, needs and services plans.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that resident R4 does not have an MD report and Dementia R2 has a MD report that is not updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
1
2
3
4
Administrator shall submit a copy of R2 and R4's medical assessments/Physician's Report.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 9 of 11


Document Has Been Signed on 08/24/2023 03:57 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that one (1) canned food container was heavily damaged and 7 expired can food items were in the food pantry, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
1
2
3
4
Administrator shall submit proof of staff training and written statement of POC.
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
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in that a fire/emergency drill has not been conducted since late 2019, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
1
2
3
4
Administrator agreed to conduct and submit proof an emergency/fire drill. The emergency drills must be conducted quarterly.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 10 of 11


Document Has Been Signed on 08/24/2023 03:57 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)((3)(c)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.
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 that none of the resident beds have mattress pads, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Administrator shall submit picture proof evidence that all resident beds have mattress pads.
Type B
Section Cited
CCR
87412(c)(1)(B)
Licensees shall maintain in the personnel records verification of required staff training and orientation. For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter in one or more of the content areas as specified in Section 87411(c)(2).
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 that staff files do not have proof of current staff training, and at least of 4 hours of annual training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2023
Plan of Correction
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Administrator shall conduct staff training and submit proof. Administrator stated that Dementia training will be conducted.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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