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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608611
Report Date: 12/05/2024
Date Signed: 12/06/2024 07:18:52 AM

Document Has Been Signed on 12/06/2024 07:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ESTAR RESIDENTIAL CAREFACILITY NUMBER:
197608611
ADMINISTRATOR/
DIRECTOR:		ARNALDO A. HUKOMFACILITY TYPE:
740
ADDRESS:8559 BOTHWELL ROADTELEPHONE:
(818) 727-1953
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 3DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Salvacion ButlerTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Lincesee Salvacion Butler and explained the reason for the visit. Administrator, Arnaldo Hukom arrived shortly after. At approximately 09:25 am, with the assistance of the Licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area.
Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked kitchen cabinet.
Bedrooms: There were five (5) bedrooms designated for residents' use and one (1) room designated for staff. All five bedrooms, in use by residents, were properly furnished with appropriate bedding and linens with sufficient lighting. Bathrooms: There are three(3) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 114.4 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. The dining room table is large enough to sit the capacity of the facility. Seating such as couches were in good repair and sit the capacity of the facility. Properly labeled medications were locked in one of the living room cabinets. The fireplace located in the living room is closed, non-operational, and blocked off.
Surrounding Grounds: Entry/exits were free of obstruction. There is a large patio table and chairs shaded by a large umbrella for clients to use in the backyard. Patio furniture was observed to be in good repair with adequate seating for the residents. Laundry room appliances were observed to be functional. Toxins are locked and stored in the garage cabinets. The smoke alarms were tested and were functional. The fire extinguishers are located in the kitchen, dining room, and living room with a charge date of February 24, 2024. (Continue on 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ESTAR RESIDENTIAL CARE
FACILITY NUMBER: 197608611
VISIT DATE: 12/05/2024
NARRATIVE
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Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms. LPA observed that S3 has no physical file. Medications: Medication and Medication Records were reviewed for proper documentation. LPA observed that medication records are not accurate. The administrator was advised to provide accurate and complete medication records for all the residents. Temperature: The facility maintains a comfortable temperature of 78 degrees Fahrenheit. Exit interview conducted. Citation issued and copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
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Document Has Been Signed on 12/06/2024 07:18 AM - It Cannot Be Edited


Created By: Mariana Agban On 12/05/2024 at 02:17 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ESTAR RESIDENTIAL CARE
FACILITY NUMBER: 197608611

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
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:

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. S3 had no physical file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Administrator will email LPA S3 employee file.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

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. Medications records were not accurate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Administrator will email LPA accurate medications form
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:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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