198603331-8-15-2024-28-AS-THEA-D86T9Y-20240815143243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603331
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:33:01 PM

Document Has Been Signed on 08/15/2024 02:33 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/ DIRECTOR:	MARQUEZ, JOSE M		FACILITY TYPE:	740
ADDRESS:	9349 ROSE STREET		TELEPHONE:	(818) 642-3668
CITY:	BELLFLOWER	STATE: CA	ZIP CODE:	90706
CAPACITY: 70		CENSUS: 62	DATE:	08/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Yakelin Carrillo - MedTech/Caregiver		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and was greeted by MedTech/Caregiver Yakelin Carrillo, shortly after Luisa Mascardo (Administrator) arrived and 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, Storage Closets Under Parking Port, Laundry Room, Dining Hall, Kitchen, Medication Room, Linen Closet and Outdoor Patio Areas. There are 3 buildings on first floor (A,B,F&G) totaling 16 Resident Rooms, 6 Full Bathrooms, 4 Half Bathrooms. Second Floor: 3 buildings totaling 28 Resident Rooms, 8 Full Bathrooms, 4 Half Bathrooms, Patio Area and Storage Closets. There are call buttons in and smoke detectors in each unit and there is an emergency sprinkler system throughout facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

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.
Physical Plant & Environment Safety: LPA toured facility, a total of 14 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms each had a signal system with call buttons that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. (Continued on 809C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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
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: 08/15/2024

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Physical Plant & Environment Safety (continued):
The fire extinguishers were observed and are fully charged. No bodies of water were observed at facility. Hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees. The passageways are free of debris/hazards and are free of obstruction All storage areas for cleaning solutions, toxins, knives, and hazardous items are properly stored are inaccessible to residents.
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 and current First Aid/CPR/AED certificates (with the exception of 1 staff that was missing First-Aid certificate, cited on 809-D), dementia training, and sufficient on-going training. Administrator Luisa Mascardo certificate expired on 5/28/24, but was able to provide proof of pending renewal and all current training were within the personnel file, CCL website showed pending renewal, expiration of 5/28/26.Resident Rights-Information: Personal Rights and Complaint signage are posted within the Dining Hall. 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 (1 of the resident files reviewed were missing their Physician Report, details cited on 809-D page). Planned Activities: LPA observed the Activity Schedule posted in the Dining Hall and toured the Activity Room, there were 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: Medications are centrally stored in locked Medication Room and in their original containers. 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. Residents with Special Health Needs: The facility is in communication with the Home Health agency to ensure the needs of residents are being met.
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 and appeal rights were provided Administrator Luisa Mascardo

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/15/2024 02:33 PM - It Cannot Be Edited

Created By: Tena Herrera On 08/15/2024 at 02:13 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: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 Staff #1 (S1) was missing their First-Aid Certificate, Administrator confirmed that this staff provides care to residents as a caregiver, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2024
	Plan of Correction
1 2 3 4	Administrator is aware that staff must complete First-Aid training prior to providing care to residents, Administrator will have S1 complete training and send LPA a copy of the valid First-Aid certificate to LPA by POC due date via email (tena.herrera@dss.ca.gov).

Type B

Section Cited

CCR

87458(b)(5)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. 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 Resident #1 (R1) file was missing their Physician Report, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2024
	Plan of Correction
1 2 3 4	Administrator to either find the Physician Report they have for R1 or email a new (updated) Physician Report for R1 to LPA via email by POC due date (tena.herrera@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:

David Sicairos

LICENSING EVALUATOR NAME:

Tena Herrera

LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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