<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700238
Report Date: 10/07/2022
Date Signed: 10/10/2022 02:27:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220725115649
FACILITY NAME:SEVEN STARS CARE HOMEFACILITY NUMBER:
342700238
ADMINISTRATOR:SARAH MIKAILFACILITY TYPE:
735
ADDRESS:1317 COFFEE VILLA DRIVETELEPHONE:
(209) 595-8534
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:6CENSUS: 4DATE:
10/07/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Calvin Goreal TIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is violating client rights.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/7/2022 at 1:15pm, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to deliver complaint findings. LPA Pascua met with, Calvin Goreal and explained the purpose of the visit. At this time it was asked that Calvin Goreal call the Facility Designated Administrator to let them know that CCL was present. Shortly after, the LPA spoke on the phone with FDA, Sarah Mikail and explained the purpose of the visit. The purpose of the visit was to deliver complaint findings to the allegation above.

During the course of the investigation, LPA Pascua conducted interviews with the administrator and 4 residents.LPA Pascua also reviewed facility files. Based on 4 out of 4 resident interviews, it was learned that 3 out of 4 residents had cell phones. 1 out of 4 residents stated that they do not use a phone. 3 out of 4 residents stated that they were asked after a resident did not follow the house rules that they were told to put their phones away at the kitchen table by 9:00pm every night and could not use them until the next morning.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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 3
Control Number 27-AS-20220725115649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SEVEN STARS CARE HOME
FACILITY NUMBER: 342700238
VISIT DATE: 10/07/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
An interview with the administrator was conducted and it was learned that the administrator asked the residents to put their personal phones out on the kitchen table by 9:00pm every night because they could not use them at night because it disturbed the other residents. LPA Pascua also reviewed facility notes and observed there to be notes that stated that a resident failed to put their phone on the kitchen table by 9:00pm. Additionally, a meeting was conducted with Valley Mountain Regional Center and it was learned that the administrator admitted that the resident's had to put their phones away at 9:00pm.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.
An Exit interview was conducted and a copy of the 9099, 9099-D and appeals rights were provided to the facility. .
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220725115649
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SEVEN STARS CARE HOME
FACILITY NUMBER: 342700238
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2022
Section Cited
CCR
85072(6)
1
2
3
4
5
6
7
85072 Personal Rights
(6) To possess and use his/her own personal items, including his/her own toilet articles.
This is not met by evidenced by:
1
2
3
4
5
6
7
Licensee will conduct additional training with staff and will ensure that they have read and understood the full regulation requirements regarding resident's personal rights.
8
9
10
11
12
13
14
Licensee made residents put their phone away at the kitchen table every night at 9:00pm and did not allow them to use their personal phones until the next morning which poses a immediate health, safety, or personal rights risk to the persons in care.
8
9
10
11
12
13
14
Licensee will send LPA a copy of the training
and sign in sheet to the LPA's email by
10/8/2022, POC date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3