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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000889
Report Date: 12/05/2023
Date Signed: 12/05/2023 11:34:09 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20231108153030
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: 26DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Lida Spicer and Kat FarrisTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Facility does not provide a safe environment for the residents
Facility is retaining a resident requiring a higher level of care
Facility does not have adequate night staff to meet the needs of the residents
Facility does not adequately communicate with the residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as physician reports. Regarding the allegations that facility does not provide a safe environment for the residents, facility is retaining a resident requiring a higher level of care, facility does not have adequate night staff to meet the needs of the residents, and facility does not adequately communicate with the residents, the investigation revealed the following: LPA toured Resident 's (R1) apartment during the investigation. LPA observed a two bedroom apartment with one room being used as storage. Resident indicated items in the storage room belonged to the resident's deceased spouse and is still processing the death. The main room and additional bedroom are cluttered but LPA observed ample walking space and an uncluttered exit path. R2 is diagnosed with Parkinson's Disease and per resident and staff, the disease is progressing. CONTINUED ON LIC 9099C DATED 12/05/2023
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20231108153030

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: 26DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Lida Spicer and Kat FarrisTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff are not ensuring that a resident receives appropriate therapy
Staff are not allowing a resident to participate in outside activities
Staff did ensure that a resident had proper representation at a meeting
Facility administrator is not qualified
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as resident correspondence. Regarding the allegations that staff are not ensuring that a resident receives appropriate therapy, staff are not allowing a resident to participate in outside activities, staff did not ensure that a resident had proper representation at a meeting and facility administrator is not qualified, the investigation revealed the following: R2 as well as staff confirm the resident had been receiving physical and occupational therapy for the resident's Parkinson's Disease. Facility documentation confirms this as well. R2 and six out of six staff indicate resident is able to participate in any activities the resident prefers and there are no restrictions put on by staff. R3 was presented a letter from the board of Easter Star as a warning for behaviors noted. R3 confirms attending the meeting on December 3, 2022 with a representative. CONTINUED ON LIC 9099C DATED 12/05/2023
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20231108153030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/05/2023
NARRATIVE
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R3 denies not be afforded that opportunity to bring representation. R3 indicated that nothing came of the warning on the letter and provided a copy of the letter to LPA. Facility administrator meets the qualifications for Administrator and has a current administrator certificate expiring on 12/15/2024. Therefore the allegations are deemed UNFOUNDED, meaning the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20231108153030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/05/2023
NARRATIVE
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Six out of six staff as well as resident confirm care being provided is meeting the resident's needs. Facility staffing schedule is as follows: Two caregivers, two LVN's and two Wellness support staff for 1st shft, one LVN, one caregiver and overlapping Wellness support for 2nd shift and two caregivers/ med techs for NOC shift. Facility is filling in with agency as needed and provided documentation as such. Facility confirms no staffing requirements are mandated by the Assisted Living Waiver program and the program conducts visits at the facility to observe residents. Six staff and three residents confirm communication in the facility is sufficient between management and residents. Facility conducts resident council meetings monthly for the residents. Management do not attend the meetings per department guidelines. Residents confirm knowing about the meetings and attending as they wish. Based on interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20231108153030

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: 26DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Lida Spicer and Kat FarrisTIME COMPLETED:
11:50 AM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff are not adequately trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as staff training records. Regarding the allegation that staff are not adequately trained, the investigation revealed the following: LPA reviewed training records for eight staff. Eight out of eight staff do not have proof of required hours and/or required topics for annual training per department guidelines. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was emailed to facility administrator along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20231108153030
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
CCR
87412(c)
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Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not being met as evidenced by:
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Licensee to ensure all staff have required training and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure staff records include documentation of required training. Eight out of eight staff do not have proof of required training. This poses a potential 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: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6