198602374-4-12-2023-11-AS-ARID-CQTSNH-20230412140134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602374
Report Date: 04/12/2023
Date Signed: 04/12/2023 02:01:50 PM

Document Has Been Signed on 04/12/2023 02:01 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	ROSTAR HOME I INC		FACILITY NUMBER:	198602374
ADMINISTRATOR:	THENG, THANA		FACILITY TYPE:	735
ADDRESS:	23311 DORSET PLACE		TELEPHONE:	(424) 263-4749
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY: 4		CENSUS: 4	DATE:	04/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Theng Thana		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 04/12/2023 at 9:00am Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with caregiver Teresita Fuertes and was later joined by Licensee Thana Theng and explained the purpose of today’s visit. The facility is licensed to operate for four (4) developmentally disabled clients of between the ages of 18 through 59. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) client rooms, one (1) staff room, one (1) office space in the living room area, two (2) bathrooms with one (1) of those bathrooms being in the staff room, a living area, a dining area and kitchen. There is an outside covered patio area with ample seating. The laundry area is in the garage. The garage is attached with access from the front of the garage and a side door directly outside the front door. Garage includes an additional refrigerator/freezer and there is parking available for one car. (LPA) and Licensee inspected the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were fully stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. Per California Code of Regulations Title 22 and California Health and safety Code. The hot water temperature in the bathroom tested at 103.3F.degree. A comfortable temperature was maintained throughout the facility. Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ROSTAR HOME I INC	FACILITY NUMBER: 198602374
	VISIT DATE: 04/12/2023

NARRATIVE

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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There is one (1) fire extinguisher fully charge located in the kitchen. Smoke detectors and carbon monoxide were operable and in working condition.

During the visit, LPA observed the facility infection control practices. LPA observed hand sanitizer available and temperature taken upon entry to the facility. LPA observed the facility has a 30-days supply of Personal Protective Equipment (PPE). There is a fully stocked first aid kit in the medicine cabinet. Emergency disaster plans are posted by near exit. Last fire drill was conducted on 03/30/2023. A reviewed of Medication Records Administration (MAR) was observed to be maintained in order and accurate.

Facility files were reviewed. Files are kept in a locked cabinet. Client files were randomly chosen for review. Client medical assessments are complete and include TB information. Clients have complete needs and services plans on file. Staff have criminal records clearances and are associated to the program. Staff have proof of in-service training. Staff files have complete health screenings and current first aid certificates.

There was one deficiency observed during this annual visit.

An exit interview was conducted and a copy of this report and appeal rights were provided to Licensee Thana Theng.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/12/2023 02:01 PM - It Cannot Be Edited

Created By: Antonine Richard On 04/12/2023 at 01:02 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ROSTAR HOME I INC	FACILITY NUMBER: 198602374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview the licensee did not comply with the section cited above, the hot water temperature tested 103.3F which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/13/2023
	Plan of Correction
1 2 3 4	The licensee adjusted the water temperature between 105.1F and 117.2F. The Licensee will create a plan to ensure future compliance. The Licensee will submit a plan of correction via email to LPA Antonine Richard@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Antonine Richard

LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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Document is an Amendment of Original Document on 04/13/2023 02:14 PM

Created By: Ulysses Coronel On 04/12/2023 at 01:04 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ROSTAR HOME I INC	FACILITY NUMBER: 198602374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

Benita Yates

LICENSING EVALUATOR NAME:

Ulysses Coronel

LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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