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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608611
Report Date: 03/22/2022
Date Signed: 03/22/2022 06:20:03 PM

Document Has Been Signed on 03/22/2022 06:20 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ESTAR RESIDENTIAL CAREFACILITY NUMBER:
197608611
ADMINISTRATOR:ARNALDO A. HUKOMFACILITY TYPE:
740
ADDRESS:8559 BOTHWELL ROADTELEPHONE:
(818) 727-1953
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: DATE:
03/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Arnaldo HukomTIME COMPLETED:
06:15 PM
NARRATIVE
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LPA Tihesha Lynn Smith met with Arnaldo Humkom and Esperanza Hukom (administrators) for an investigative visit and during the course of the investigation citations not having to do with the complaint were observed to be in deficiency.

A tour of the physical plant was completed and the following was noted:

The cabinets in dining area (top and bottom cabinets) where the medication is stored was left unlocked. A female identified as Jane Gorspe (friend of staff Herminia Lazo) performing covid protocols by checking LPA temperature is not associated with the facility.

LPA also observed the bathroom (that is located to the right of the main entry door) has a large piece of the sink counter top missing on the corner edge and drywall at bottom of wall next to side of toilet is peeling, warped, and needs repair.

Citations given, exit interview conducted. Copy of report provided

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/22/2022 06:20 PM - It Cannot Be Edited


Created By: Tihesha Smith On 03/22/2022 at 04:42 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: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2022
Section Cited
CCR
80019(e)(3)

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Criminal Record Clearance. Individuals subject to criminal record reviews shall, prior to working, residing or volunteering in a licensed facility, request and be approved for a transfer of a criminal record exemption, unless, upon request for the transfer, the Department permits the individual to be employed, reside or be present at the facility.
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The licensee shall submit a self certification that this incident shall not occur again. The licensee shall make sure that staff and or volunteers prior to working in facility shall have fingerprint clearance and association to the facility.

Immediate civil penalty assessed for 100.00 max
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Jane (friend of staff Herminia Lazo ) performing covid protocols (taking temperature) and was not associated to the facility during LPA visit today.

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In order to clear deficiency the self certification needs to be received by
LPA within a 24 hr period. Licensee may fax it to 818-596-4376.
Type A
03/22/2022
Section Cited
CCR87465(h)(2)

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Centrally stored medicines shall be kept in a safe and locked place not accessible to persons other than employees responsible for the supervision of the centrally stored medication.Medication cabinets observed to be unlocked.This poses an immediate health and safety risk to residents in care.
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Staff locked the medicine cabinets. Therefore this citation is cleared during this visit.
Type B
03/22/2022
Section Cited
CCR
80087(a)

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80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.
1. Bathroom missing large piece of top edge countertop
2. Bathroom wall at bottom by side of toilet had peeling paint, warped drywall that needs repair.
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Licensee will make sure facility is maintained and in good repair at all times.
The facility shall work with CCL and address the following:
Repair/ or replace sink counter top and repair warped drywall.
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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
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