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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425567
Report Date: 11/06/2023
Date Signed: 11/06/2023 09:56:53 AM


Document Has Been Signed on 11/06/2023 09:56 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
CCLD Regional Office,
, CA



FACILITY NAME:RISING STAR CARE HOMEFACILITY NUMBER:
336425567
ADMINISTRATOR:JAMES REEDFACILITY TYPE:
740
ADDRESS:30045 AUDELO STREETTELEPHONE:
(951) 609-3300
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:0CENSUS: 0DATE:
11/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:James Reed, Licensee/Administrator TIME COMPLETED:
09:00 AM
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Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit. While LPA was conducting an investigation pertaining to complaint control number 18-AS-20201229100435, and LPA observed the following deficiencies:

Staff did not seek medical attention for resident in a timely manner. The Department conducted interviews and reviewed facility and hospital documentation regarding Resident #1 (R1). u

On December 28, 2020 R1 was admitted to the hospital, at the time of admission R1 was observed to have ten (10) pressure injuries throughout R1's body (left shoulder, left heel, left foot, left hip, left buttock, right ear, left elbow, right buttock, right heel, and right upper back).

The pressure injuries ranged from Stage two (2) to unstageable (left buttock - 7x5 cm, and right ear - necrotic). R1 was not given any medical attention for the wounds until they were admitted to the hospital for an unrelated matter.

The facility is being cited in accordance to Title 22, Division 6, Chapter 8, Article 4 of the California Code of Regulations.

An exit interview was conducted and a copy of this report, 809-D, Appeal Rights and the confidential names list (LIC811), was provided to James Reed, Licensee/Administrator.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2023
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 11/06/2023 09:56 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
CCLD Regional Office,
, CA


FACILITY NAME: RISING STAR CARE HOME
FACILITY NUMBER: 336425567

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/20/2023
Section Cited
CCR
87466

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87466 Observation of Resident The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...shall ensure that such changes are documented and brought to the attention of the resident's physician
and the resident's responsible person, if any
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The Licensee agrees to conduct an inservice on when to seek medical attention. Proof of POC is to be submitted by 5pm on the due date indicated.
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This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation 1 time. Staff did not observe R1 to have a change of condition. This poses a potential health, safety and personal rights risk to persons 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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