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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603331
Report Date: 12/12/2024
Date Signed: 12/12/2024 02:09:37 PM

Document Has Been Signed on 12/12/2024 02:09 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 LIVINGFACILITY NUMBER:
198603331
ADMINISTRATOR/
DIRECTOR:		MARQUEZ, JOSE MFACILITY TYPE:
740
ADDRESS:9349 ROSE STREETTELEPHONE:
(818) 642-3668
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 70CENSUS: 57DATE:
12/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:22 AM
MET WITH:Jennifer Serrano - Acting AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Tena Herrera conducted a Case Management Visit-Deficiencies on, stemming from initial complaint investigation conducted on 12/12/24, complaint control # 28-AS-20241209121049. LPA Herrera met with Jennifer Serrano and Silvia Vidal and explained the reason for visit.

Case Management-Deficiencies findings:

During complaint investigation it was revealed that facility Administrator/Licensee failed to report to the department of renovations that were being done to the facility dining area. Renovations began on approximately 11/13/24 and was stopped due to failure to obtain necessary approvals/permits by the City of Bellflower (failure for permit, cited on complaint visit). LPA was never informed of the remodel nor were there any incident reports provided to the department indicating there were plans for renovations.

LPA will issue a deficiency on Reporting Requirements that can be found on the LIC809-D.

Exit interview held, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 12/12/2024 02:09 PM - It Cannot Be Edited


Created By: Tena Herrera On 12/12/2024 at 01:53 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHT STAR ASSISTED LIVING
FACILITY NUMBER: 198603331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2024
Section Cited
CCR
80086(a)

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80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This standard was not met as evidence by:
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Administrator/Licensee to submit an Incident Report to LPA by POC due date that discloses all renovations that have been done when it started, why it stopped and when it is schedule to end. Incident report can be emailed to LPA tena.herrera@dss.ca.gov
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Administrator/Licensee failed to report to the department of renovations that were being done to the facility dining area. Renovations began on approximately 11/13/24 and licensing became aware of remodel to dining due to a complaint that was generated on 12/9/24.
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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
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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