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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000126
Report Date: 02/16/2022
Date Signed: 02/16/2022 03:03:10 PM


Document Has Been Signed on 02/16/2022 03:03 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:STAR DUST HOMEFACILITY NUMBER:
306000126
ADMINISTRATOR:RIVERA, FATIMAFACILITY TYPE:
740
ADDRESS:1825 SAMAR DR.TELEPHONE:
(714) 429-1658
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 4DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Licensee Fatima RiveraTIME COMPLETED:
12:17 PM
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Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to the facility today to conduct required 1 year inspection. During today’s visit, LPA met with Licensee Fatima Rivera and explain the purpose of today's visit. LPA Frank toured the facility, inspected resident rooms and bathrooms, reviewed staff training records. LPA Frank reviewed centrally stored medications and records, reviewed food services, and inspected the kitchen. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log, COVID posters throughout the facility.
In addition, LPA Frank tested the hot water temperature, which measured 110.7 degrees F in resident
bathroom. Resident areas were noted to be a comfortable temperature. Smoke detectors and carbon
monoxide detectors were tested and found to be operational. The facility also has fire extinguisher that was
mounted and charged. LPA Frank confirmed food supply: 2 day supply of perishables and 7 day supply of
non-perishable food is available for the number of residents present. Hygiene supplies and supply of linen
were observed in quantities for the number of residents in care. LPA observed locked areas for toxins and
hazardous items. Medication were observed locked in cabinet.
LPA observe the facility to be clean and in good repair.
LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808)
Mitigation Plan and 3) Current Liability Insurance, Designation of Administrative Responsibility (LIC308) and
Personnel Report (LIC500);
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.
This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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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