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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603569
Report Date: 08/12/2024
Date Signed: 08/12/2024 12:15:34 PM

Document Has Been Signed on 08/12/2024 12:15 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:CENTRAL STAR RANCHO LOS AMIGOS CRISIS RESIDENTIALFACILITY NUMBER:
198603569
ADMINISTRATOR/
DIRECTOR:		HONORE HARRELL, ALISHAFACILITY TYPE:
772
ADDRESS:7745 LEEDS STREETTELEPHONE:
(562) 719-2866
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 16CENSUS: 14DATE:
08/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Alisha Honore Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tyler Reyes conducted the required annual continuation inspection, focusing the remaining domains. LPA arrived unannounced and met with Alisha Honore Administrator who assisted with the visit. The facility is licensed to serve 16 ambulatory clients.

This is a 2-story facility located in an industrial area in Downey, Ca. A tour of the facility includes: First Floor: 2 client bedrooms, janitor closet, staff restroom, living room, nurse station, 2 restrooms, 1 shower room, medication room, multi-purpose room, dining room, kitchen, assessment room, storage room (with emergency food supply), program director office, laundry room, control panel room, and an intake room with restroom/shower. Second floor: 6 client bedrooms, administrators office, 3 shower rooms, 3 restrooms, laundry room, clinician station, staff restroom, and janitor closet.

LPA completed the following domains:

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


Physical Plant & Environment Safety: LPA toured facility and observed 6 clients’ bedrooms, each room had the required furniture for comfort and safety and had sufficient lighting. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available and stored in a storage room. The hot water temperature was tested throughout the facility shower rooms and measured within the required range of 105-120 degrees. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in a secured/locked area and inaccessible to clients. The last Fire/Emergency Drill was conducted on 7/30/24. Smoke detectors and carbon monoxide detectors are operable and in compliance, there is an emergency sprinkler system throughout the facility. The fire extinguishers were observed and are fully charged.
(Continued on 809-C)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
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 5
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: CENTRAL STAR RANCHO LOS AMIGOS CRISIS RESIDENTIAL
FACILITY NUMBER: 198603569
VISIT DATE: 08/12/2024
NARRATIVE
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Operational Requirements: The facility maintains accurate records of accounts, personal property and/or valuables. The facility provides care and supervision as necessary to meet the client’s needs.
Staffing: There facility appears to have two direct care staff on duty, on the premises any time the clients are in the facility and seem to have sufficient staffing at all times.
Personnel Records-Training: Staff has criminal record clearance, current first aid and CPR, and ongoing training. Staff files are maintained at the facility and kept in the program director’s office.
Client Rights-Information: Clients are provided with telephone and internet at the facility.
Client Records-Incident Reports: Client files are kept in a electronically secured and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. Facility has a food waiver on file where facility receives daily deliveries of one hot meal and 2 cold meals. LPA observed emergency food supply and there was sufficient amount available to meet the needs of the clients in care.
Health Related Service: Staff designated to administer medication has the proper training on file. Medication is properly labeled and are centrally stored within the Medication Room and are in their original containers. During the visit, LPA reviewed 6 clients’ medication. Based on LPA Reyes's review of Client#1's (C1) Medication Sheet for the month of August 2024. C1’s AM Medication DULoxetine HCL DR 20 MG (Take 2 Capsules By Mouth Every Morning) was last documented on the Administered History log for 8/7/2024 at 7:47 AM. LPA reviewed C1's medication on 8/8/24. Staff#1 (S1) stated to LPA Reyes the reason for not logging C1's medication log was due to insufficient time in the day. During review of C1’s AM Medication DULoxetine HCL DR 20 MG it was observed the prescription has been given more than prescribed by the physician. C1’s AM Medication DULoxetine HCL DR 20 MG was delivered to facility on 7/23/24 at 20:10:47. C1 was administered 18 dosages of DULoxetine HCL DR 20 MG from 7/24/24 to 8/9/24.
Incidental Medical & Dental: All medications for clients are kept locked and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.
(Continued on 809-C)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: CENTRAL STAR RANCHO LOS AMIGOS CRISIS RESIDENTIAL
FACILITY NUMBER: 198603569
VISIT DATE: 08/12/2024
NARRATIVE
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During today’s visit LPA conducted 3 staff interviews and 1 client interviews.

Exit interview conducted. Deficiencies cited on LIC809-D. A copy of the report and appeal rights was given to Administrator Alisha Honore
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/12/2024 12:15 PM - It Cannot Be Edited


Created By: Tyler Reyes On 08/12/2024 at 11:48 AM
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: CENTRAL STAR RANCHO LOS AMIGOS CRISIS RESIDENTIAL
FACILITY NUMBER: 198603569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, and record review, the licensee did not comply with the section cited above. During review of C1’s AM Medication DULoxetine HCL DR 20 MG it was observed the prescription has been given more than prescribed by the physician. C1’s AM Medication DULoxetine HCL DR 20 MG was delivered to facility on 7/23/24 at 20:10:47. C1 was administered 18 dosages of DULoxetine HCL DR 20 MG from 7/24/24 to 8/9/24 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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Administrator will provide LPA Reyes with the following documents in-service training for all LVN and LPT
staff on medication documentation and that R1's physician was notified.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/12/2024 12:15 PM - It Cannot Be Edited


Created By: Tyler Reyes On 08/12/2024 at 11:48 AM
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: CENTRAL STAR RANCHO LOS AMIGOS CRISIS RESIDENTIAL
FACILITY NUMBER: 198603569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81075(o)(4)
Health-Related Services
(o) For each client that the licensee determines there is a need, a licensee shall develop an individual medication-management plan provided all of the following conditions are met: (4) The licensee shall ensure that a log is maintained each time medication is taken by the client with the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above LPA Reyes's review of Client#1's (C1) Medication Sheet for the month of August 2024. C1’s AM Medication DULoxetine HCL DR 20 MG (Take 2 Capsules By Mouth Every Morning) was last documented on the Administered History log for 8/7/2024 at 7:47 AM. LPA reviewed C1's medication on 8/8/24. Staff#1 (S1) stated to LPA Reyes the reason for not logging C1's medication log was due to insufficient time in the day which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2024
Plan of Correction
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Administrator will provide LPA Reyes with the following documents in-service training for all LVN and LPT
staff on medication documentation and that R1's physician was notified.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Tyler Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


LIC809 (FAS) - (06/04)
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