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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000889
Report Date: 02/08/2024
Date Signed: 02/08/2024 02:52:06 PM


Document Has Been Signed on 02/08/2024 02:52 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:SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CAFACILITY NUMBER:
306000889
ADMINISTRATOR:KAT FARRISFACILITY TYPE:
741
ADDRESS:16850 E. BASTANCHURY ROADTELEPHONE:
(714) 577-9281
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:76CENSUS: 29DATE:
02/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Kat FarrisTIME COMPLETED:
03:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report received by the department on 02/02/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 01/28/2024 indicated that Staff 1 (S1) had inserted a diabetic sensor/ glucose monitor into Resident 1's (R1) arm. Facility investigation revealed that R1's new sensor had not arrived at the facility timely and the resident would need to utilize a finger stick instead of the sensor in the interim. Resident spoke with S1 regarding the situation and the staff inserted a spare sensor in the resident's arm. Facility observed the staff inserting the sensor on video surveillance. S1 is employed at the facility as an Activities Assistant and is not a skilled professional. S1 is receiving a write-up which was provided to LPA and further action from facility is pending.



Based on the observations made from today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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 02/08/2024 02:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CA
FACILITY NUMBER: 306000889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
87628(a)

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The licensee shall be permitted to accept a resident who has diabetes if the resident is able to perform his/her own glucose testing.., and is able to administer his/her own medication including medication.., or has it administered by an appropriately skilled professional. This req is not being met as evidenced by:
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Licensee to provide an in-service on glucose testing/ injections and forward proof to LPA by POC due date.
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Based on interviews conducted, the Licensee failed to ensure glucose testing is performed by an appropriately skilled professional. The activities assistant inserted a diabetic sensor/ glucose monitor into R1's arm. This poses an immediate health and safety risk to residents in care.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
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