198603331-10-21-2023-28-AS-THEA-CWTU7S-20231021152026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603331
Report Date: 10/21/2023
Date Signed: 10/21/2023 03:20:42 PM

Document Has Been Signed on 10/21/2023 03:20 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	BRIGHT STAR ASSISTED LIVING		FACILITY NUMBER:	198603331
ADMINISTRATOR:	MARQUEZ, JOSE M		FACILITY TYPE:	740
ADDRESS:	9349 ROSE STREET		TELEPHONE:	(818) 642-3668
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY:	70	CENSUS: 61	DATE:	10/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Luisa Mascardo - Administrator		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and was greeted by MedTech Venus Andres and later by Yakelin Carrillo (caregiver) and Luisa Mascardo (Administrator) who later assisted with the visit. The purpose for the visit was explained upon arrival. The facility is licensed to serve 70 Ambulatory (of which 50 may be Non-Ambulatory) residents ages 60 and over. With an approved hospice waiver for 20. (there are currently no residents on hospice at the facility).

This is a two-story facility located in Bellflower, Ca. A tour of the facility includes: First Floor: Front Office, Conference Room with Storage Room and File Room, Activity Room, 16 Resident Rooms, 5 Full Bathrooms, 2 Half Bathroom, Dining Hall, Kitchen, Medication Room, Storage Rooms, Linen Closet and Outdoor Patio Area. Second Floor: 28 Resident Rooms, 6 Full Bathrooms, 4 Half Bathrooms, Patio Area and Storage Closets.

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.

Operational Requirements: The facility maintains a current Plan of Operation and an approved Fire Clearance. The facility maintains the required Liability Insurance covering injury to residents and guests, however, the coverage for total annual aggregate is not within the required amount, details provided on the 809D page.
Physical Plant & Environment Safety: LPA toured facility there are a total of 44 resident bedrooms (36 double rooms and 8 single rooms) a total of 15 resident rooms were checked and bedding/closet/drawer space to accommodate each resident comfortably was available. The passageways and patio areas were observed to be free of debris/hazards and are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for residents.
(Continued on 809C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

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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Document Has Been Signed on 10/21/2023 03:20 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHT STAR ASSISTED LIVING	FACILITY NUMBER: 198603331
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 as the liability insurance was observed to have the required $1,000,000 coverage for injury to residents and guests but only has $2,000,000 of total annual aggregate coverage which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/04/2023
	Plan of Correction
1 2 3 4	Licensee to update the Liability Insurance Policy to meet the required coverage and email a copy of new Certificate of Liability Insurance to LPA via email by POC due date.

Type B

Section Cited

HSC

1569.695(f)(1)

Other Provisions

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and conversation with Administrator, the licensee did not comply with the section cited above in 2 out of 2 stairwells did not have the required evacuation chairs, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/04/2023
	Plan of Correction
1 2 3 4	Administrator stated they will purchase the required evacuation chairs to meet the regulation and place them at each stairwell. Administrator to email a copy of the receipt of purchase to LPA by POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHT STAR ASSISTED LIVING	FACILITY NUMBER: 198603331
	VISIT DATE: 10/21/2023

NARRATIVE

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The hot water temperature was tested throughout the facility and were above the required range of 105-120 degrees F, details will be documented on 809D page. All storage areas for cleaning solutions, toxins, knives, and hazardous items are properly stored are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers were observed and are fully charged. Facility operates a signal system LPA observed call buttons in rooms and restrooms that were toured.
Staffing: There appears to be sufficient staffing at all times with at least one nighttime staff that is able to operate the facility signal system, is familiar with emergency procedures and has a current CPR and First Aid training on file.
Personnel Records-Training: Staff files are maintained in a locked storage room within the Conference Room. Staff files observed during today’s visit have criminal record clearance, health screening with negative TB results and current First Aid/CPR/AED certificates and sufficient on-going training. Administrator Luisa Mascardo certificate expires on 5/28/24.
Resident Rights-Information: Personal Rights and Complaint signage are posted within the Dining Hall. The facility does not have any clients that require postural supports. Facility provides a telephone land line for the residents.
Resident Records-Incident Reports: Resident files are maintained in the Administrators Office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Planned Activities: Residents at the facility are encouraged to engage in planned activities. LPA observed the Activity Schedule posted in the Dining Hall and toured the Activity Room, there was books, magazines, supplies for activities, board games and puzzles readily available for residents. The facility has a designated Activity Director.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: The facility provides assistance in meeting necessary medical and dental needs to the residents. Medications are centrally stored within the locked Medication Room and in their original containers. During the visit today, LPA reviewed 7 residents’ medications, no issues were observed.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills. The facility does not have the required evacuation chairs at each stairwell, additional information documented on 809D.
(continued on 809C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHT STAR ASSISTED LIVING	FACILITY NUMBER: 198603331
	VISIT DATE: 10/21/2023

NARRATIVE

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Residents with Special Health Needs: There is only one resident at the facility that utilizes services with Home Health and the facility is in communication with the agency to ensure the needs of resident are being met. The facility does not have any bedridden residents nor residents that have postural supports.

LPA conducted 4 staff interviews and 5 resident interviews and reviewed 6 staff files and 6 resident files during today’s visit with no issues.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D.

Exit interview was held and a copy of the report was provided Administrator Luisa Mascardo

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/21/2023 03:20 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHT STAR ASSISTED LIVING	FACILITY NUMBER: 198603331
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

(e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). 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 as LPA tested water temperature in Dining Hall resident restrooms and upstairs restrooms, temperature readings in 4 of the restrooms read 122.0, 132.4, 134.0 and 138.2 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2023
	Plan of Correction
1 2 3 4	Administrator to create a water temperature log for the next 5 days and document the date, time, and water temperature reading to ensure that water temperature is maintained within the required regulation. Water temperature should be tested 3 times daily, morning, day, evening and must be tested throughout the facility restrooms not just one restroom. This log is to be sent to LPA via email by 10/27/23. water temperature was lowered during visit

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

LIC809 (FAS) - (06/04)

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