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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336424655
Report Date: 05/17/2024
Date Signed: 05/17/2024 11:50:48 AM


Document Has Been Signed on 05/17/2024 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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: 6DATE:
05/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Caregiver, Rita GamezTIME COMPLETED:
12:03 PM
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Licensing Program Analyst, (LPA) Kathleen Banrasavong arrived unannounced to follow up on a death report (LIC 624A) received by Community Care Licensing, Riverside Adult and Senior Regional Office on 05/06/2024. LPA identified herself, and met with Caregiver, Rita Gamez, and explained the purpose of the visit. Additionally, the LPA spoke to the Assistant Administrator, Marilyn Ponteres over the phone to explain the purpose of the visit. Gamez accompanied LPA on a tour of the facility. There were no health and safety concerns present during the visit.


The department received a death report for resident 1 (R1). R1 passed away on 04/22/2024. Under the Title 22, Division 6 Chapter 8 Article 04. Operating Requirements 87211 (a) (1) (A), a deficiency will be cited due to the Administrator not reporting to the Department until 05/06/2024, the 14th day after resident 1(R1) had passed away.


An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC809-D, the LIC811 and Appeal Rights were provided to the Caregiver, Rita Gamez, as evidenced by her signature.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024
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 05/17/2024 11:50 AM - 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
RIVERSIDE ASC, 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: 05/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
HSC
87211(a)(1)(A)

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as...
(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...(A) Death of any resident from any cause regardless of where the death occurred...This requirement was not being met as evidenced by:
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The Assistant Administrator, Marilyn Ponteres has agreed to submit to the LPA a document that she has read the regulation and training that will be provided to the staff, POC is due by 05/24/2024.
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Based on the LPA’s record reviews and interview with the Assistant Administrator, Marilyn Ponteres, it was determined that the Assistant Administrator failed to report the death of R1 on 04/22/2024 until 05/06/2024, to CCL the death within 7days. This poses a 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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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