197607901-7-16-2024-28-AS-NGAA-D78TY7-20240716150817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607901
Report Date: 07/16/2024
Date Signed: 07/16/2024 03:08:31 PM

Document Has Been Signed on 07/16/2024 03:08 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 HOME		FACILITY NUMBER:	197607901
ADMINISTRATOR:	ANA F. DUENAS		FACILITY TYPE:	740
ADDRESS:	1704 KERRY COURT		TELEPHONE:	(626) 810-4104
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91792
CAPACITY:	6	CENSUS: 6	DATE:	07/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Ana Duenas, Licensee		TIME COMPLETED:	03:10 PM

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Licensing Program Analyst (LPA) Galarza conducted an unannounced annual inspection visit. The purpose of the visit was explained to Administrator Ana Duenas. The facility serves elderly residents ages 60 and older. A hospice and Dementia waiver is in place. It consists of 4 resident rooms, 2 bathrooms, dining room/ living room, outdoor patio area, and attached garage. The inspection was completed using the CARE tools. Twelve (12) CARE tools domains were reviewed.

The following were observed/inspected:

Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs).

Operational Requirements: A hospice waiver for 3 residents has been approved. A fire clearance for 5 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 4 only. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 8/26/2024.

Physical Plant/Environment Safety: 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. Cleaning supplies and toxic substances are inaccessible to residents. The facility has fully charged fire extinguishers. Water temperature readings did measured within the required 105 - 120 degrees Fahrenheit. Facility has a fire pull-alarm.

Licensee has not kept Fire/Emergency Disaster drill logs in years.

Staffing: A total of 3 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Administrator certificate expires 7/26/2025. Staff have criminal background clearance and training. Three (3) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training. Administrator's 1st Aid/CPR training was not on file.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STARLIGHT CARE HOME	FACILITY NUMBER: 197607901
	VISIT DATE: 07/16/2024

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Resident Records/Incident Reports: A total of six (6) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. No centrally stored medication records or medication administration records are in place.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. 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. No residents are on modified diets.

Incident Medical and Dental: Six (6) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: Three (3) residents are receiving hospice services and zero (0) resident receive home health services. Two (2) residents have a Dementia diagnosis. Full bed rails for mobility assistance were observed in hospice resident's rooms. No residents have prohibited health conditions.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Licensee Ana Duenas. A copy of the report and appeal rights was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/16/2024 03:08 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: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

FIRE SAFETY All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 a total of 2 out of 4 resident rooms inspected did not have smoke detectors with batteries, which poses an immediate health, safety or personal rights risk to persons in care. * Pictures were taken.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure that all smoke detectors are always operable. Facility staff replaced batteries during the visit. **Citation was cleared.

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the knives and sharps cabinet in the kitchen was unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Staff locked knives/sharps cabinet. Licensee shall train staff and submit proof of staff training 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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/16/2024 03:08 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: 07/16/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that LPA observed live-in staff (S2) sleeps in the garage. In addition, live- in staff (S3) sleeps in the living room and has their belongings in the garage, which poses a potential health, safety or personal rights risk to persons in care. Pictures were taken.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit: 1. Written plan of correction addressing live-in staff accommodations 2. If there are Plan of Operation changes submit an updated plan and facility sketch. *NOTE: The plan of operation and facility sketch do not state there will be live-in staff.

Type B

Section Cited

CCR

87705(k)(3)

Care of Persons with Dementia Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement was 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 it failed to keep/provide a copy of emergency drills in facility file. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit proof of emergency drill log signed by facility staff.

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/16/2024 03:08 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: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 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 medications in pill bottles & 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: 07/17/2024
	Plan of Correction
1 2 3 4	Licensee shall ensure centrally stored medication records are kept for all residents in care. Submit by TOMORROW proof of centrally stored medication form and/or MAR records provided by resident pharmacies. *NOTE: Same citation was issued last year, but was not corrected.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that resident (R5’s) medications were observed to be unlocked on a pill container on top of the dining table, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/17/2024
	Plan of Correction
1 2 3 4	Licensee shall submit proof that staff were trained in medication storage requirements.

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 07/16/2024 03:08 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: 07/16/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that resident (R6's) bed does not have a matress pad, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Administrator shall submit a purchase order receipt and picture of mattress pad on resident (R6’s) bed.

Type B

Section Cited

CCR

87311

Telephones

All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. 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 licensee/Administrator terminated telephone land line services in 2024, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2024
	Plan of Correction
1 2 3 4	Licensee shall submit proof that telephone service has been restored.

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

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