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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424655
Report Date: 01/27/2023
Date Signed: 01/27/2023 02:30:11 PM


Document Has Been Signed on 01/27/2023 02:30 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:MORNING STAR R.C.F.E.FACILITY NUMBER:
336424655
ADMINISTRATOR:JONAS C. ACUNAFACILITY TYPE:
740
ADDRESS:32175 CATHEDRAL CANYON DRIVETELEPHONE:
(760) 992-8901
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:12CENSUS: 8DATE:
01/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Marilyn Ponteres, Assistant AdministratorTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to investigate a complaint (18-AS-20230126115904). LPA identified himself, and met with Caregiver Rita Gamez, and explained the purpose of the visit. Gamez accompanied LPA on a tour of the facility.

During interview with Assistant Administrator Marilyn Ponteres, and record review, it was discovered that the facility is not reporting incidents to the Department. On 1/19/2023, Resident One (R1) sustained a fall. On 1/20/2023, Resident Two (R2) sustained a fall and had lacerations on their face. Neither incident was reported to CCL on those dates. Deficiency cited.

An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC809-D, and Appeal Rights.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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 01/27/2023 02:30 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: MORNING STAR R.C.F.E.
FACILITY NUMBER: 336424655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not being met as evidenced by:
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Licensee agrees to submit a Unusual Incident Report (UIR) to CCL involving the fall of R1 on 1/19/23 and R2 on 1/20/23. Licensee further agrees to conduct in-service training regarding reporting requirements and submit training to LPA by POC date along with the UIR for R1.
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Based on LPA's interview, and record review, it was determined that R1 fell on 1/19/2023, and R2 fell on 1/20/2023. Both incidents were not reported to CCL per Title 22. This poses a potential health and safety and personal rights 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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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