198603331-9-15-2025-28-AS-DKOI-DLK29E-20250915171149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603331
Report Date: 09/15/2025
Date Signed: 09/15/2025 05:12:29 PM

Document Has Been Signed on 09/15/2025 05:12 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
MONTEREY PARK ASC, 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: 63	DATE:	09/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Jennifer Serrano, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

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Licensing Program Analyst (LPA) Daniel Konishi conducted the required annual inspection. LPA arrived unannounced and met the Administrator, Jennifer Serrano and the LPA explained the purpose of the visit. 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.

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. The 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: This is a two-story 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 the 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 the facility. LPA toured facility, a total of 11 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHT STAR ASSISTED LIVING	FACILITY NUMBER: 198603331
	VISIT DATE: 09/15/2025

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Physical Plant & Environment Safety (continued): LPA observed two (2) evacuation chairs that were mounted nearby the stairways. The residents’ rooms each had a signal system with call buttons that were tested and operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers observed are fully charged and last inspected on 11/22/2024. No bodies of water were observed at the facility. Hot water temperature was tested in 11 bathrooms throughout the facility and measured from 105.2 degrees F to 118.4 degrees F which are within the required range of 105-120 degrees F. The passageways are free of debris/hazards and are free of obstruction. All storage areas for cleaning solutions, toxins, knives, and hazardous items that are properly stored are inaccessible to residents.

Staffing: There appears to be sufficient staffing at all times with at least one night-time staff that is able to operate the facility signal system, is familiar with emergency procedures and has current CPR and First Aid training on file.

Personnel Records-Training: LPA reviewed five (5) staff files which includes personnel record, criminal record clearance, health screening, TB clearance, valid First Aid/CPR/AED training, Employee Rights, dementia training, and sufficient on-going training. Administrator’s certificate expired on 03/12/2027.

Resident Rights-Information: Personal Rights and Complaint signage are posted within the Dining Hall.

Resident Records-Incident Reports: LPA reviewed seven (7) resident files that include: Admission Agreements, Identification & Emergency Information, current Physician's Report, TB Clearance, Ambulatory Status, Pre-admission appraisal/Appraisal Needs & Services Plan, and Personal Rights.

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 its 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. LPA reviewed seven (7) residents’ medications and there were no issues.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BRIGHT STAR ASSISTED LIVING	FACILITY NUMBER: 198603331
	VISIT DATE: 09/15/2025

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Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. The facility maintains documentation of the required emergency drills. The last Fire Drill was conducted on 07/24/2025.

Residents with Special Health Needs: The facility is in communication with the Home Health agency to ensure the needs of residents are being met. There are currently no residents under hospice service. LPA observed half bed rails in Resident #4 (R4's) bedroom and physician's order for a half bed rail for Resident #4 (R4) was not in file.

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 Jennfier Serrano.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/15/2025 05:12 PM - It Cannot Be Edited

Created By: Daniel Konishi On 09/15/2025 at 05:01 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: 09/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in, as Resident #4 (R4) has a half bed rail without a physician's order on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2025
	Plan of Correction
1 2 3 4	The administrator is to ensure that physicians’ orders are kept in Resident #4 (R4’s) file that has bed rails at all times. The administrator is to either obtain a physician's order for the bed rails to the LPA or remove them if unnecessary submit a plan by the POC due date.

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.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Daniel Konishi
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

LIC809 (FAS) - (06/04)

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