198602375-4-14-2023-11-AS-ARID-CQVVZR-20230414165306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602375
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:53:13 PM

Document Has Been Signed on 04/14/2023 04:53 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 II INC		FACILITY NUMBER:	198602375
ADMINISTRATOR:	THENG, THANA		FACILITY TYPE:	735
ADDRESS:	1527 WEST 247TH PLACE		TELEPHONE:	(310) 326-1746
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY: 4		CENSUS: 4	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	THENG THANA		TIME COMPLETED:	05:15 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 04/14/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with 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 64, which two (2) of them are ambulatory. 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, two (2) bathrooms, a living area, a dining area and kitchen. There is an outside shaded patio area with ample seating. The laundry area is in the garage. There is a detached garage with access from the front of the garage only. Garage includes an additional refrigerator/freezer and is used for storage. LPA and Licensee toured 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 adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 113.6F degrees in the bathroom. A comfortable temperature was maintained in the facility. Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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 II INC	FACILITY NUMBER: 198602375
	VISIT DATE: 04/14/2023

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. The last fire drill was conducted on 03/30/2023. Smoke detectors and carbon monoxide were operable and in working condition. A reviewed of Medication Administration Record (MAR) was observed to be maintained in order and accurate. The facility files were reviewed. The facility Liability Insurance and license fees were reviewed and are current.

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 kitchen area.

There were deficiencies cited during this inspection visit.

An exit interview was held

A copy of this report and appeal rights were provided to Thana Theng.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/14/2023 04:53 PM - It Cannot Be Edited

Created By: Antonine Richard On 04/14/2023 at 04:10 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 II INC	FACILITY NUMBER: 198602375
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(11)

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: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation interview record review, the licensee did not comply with the section cited above Melba Paragas, and Elsi Moskito are missing Tuberculosis test documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	Licensee will create a plan to ensure future compliance. The licensee will submit the documents as specified in the Section 80065(g). to LPA vial emai.l Antonine.richard@dss.ca.gov

Type B

Section Cited

CCR

80066(b)(2)

Personnel Records

(b) Personnel records shall be maintained for all volunteers and shall contain the following: (2) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above, Melba paragas and Elsi Moskito are missing Tuberculosis test documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	Licensee will create a plan to ensure future compliance. The licensee with submit the documents as specified in Section 80066(b)(2). to LPA via email. Antonine.Richard@dss.ca.gov

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: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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