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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003810
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:40:09 PM

Document Has Been Signed on 09/22/2022 01:40 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:STARLIGHT GUEST HOMEFACILITY NUMBER:
306003810
ADMINISTRATOR:CAROL ODULIOFACILITY TYPE:
735
ADDRESS:11232 LOARA STREETTELEPHONE:
(714) 537-8045
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 6DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Hygeia Beyer, Muriel LapinedTIME COMPLETED:
01:50 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff #1 (S1) Hygeia Beyer and Staff #2 (S2) Muriel Lapined and discussed the purpose of the inspection. Administrator (AD) Carol Odulio was not present. During the inspection, LPA and staff conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

LPA and staff observed there were 3 staff present, wearing PPE. LPA observed 3 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.
During the inspection, LPA and staff observed the following: lighter fluid, paint, and spray paint accessible in the non-lockable garage; medications accessible in the unlocked staff room with the key to the staff room not present at the facility.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, and communication and emergency plan. LPA requested and reviewed resident roster, staff roster, resident files, staff files, emergency plan, and COVID-19 mitigation plan. LPA provided technical assistance regarding N95 Fit Testing.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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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Document Has Been Signed on 09/22/2022 01:40 PM - It Cannot Be Edited


Created By: Sean Haddad On 09/22/2022 at 01:35 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STARLIGHT GUEST HOME
FACILITY NUMBER: 306003810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)


80087 Buildings and Grounds: (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure toxins and medications were inaccessible to residents in the garage and staff room, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/23/2022
Plan of Correction
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Licensee stated they will reverse the lock on the garage door and obtain the key to the staff room door and submit proof to LPA by POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022


LIC809 (FAS) - (06/04)
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