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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602372
Report Date: 11/25/2024
Date Signed: 11/25/2024 10:45:51 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/23/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240523164416
FACILITY NAME:STAR RESIDENTIALFACILITY NUMBER:
374602372
ADMINISTRATOR:ALBERT SOUZAFACILITY TYPE:
740
ADDRESS:4469 ROBBINS STREETTELEPHONE:
(858) 622-1933
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 3DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrative AssistantTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff left residents unsupervised
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Administrative Assistant Emily Purvis.

It was alleged staff left residents unsupervised. On 05/23/2024, it was reported to the Department the facility administrator had left residents unattended and without staff to provide care and supervision.

Review of text messages obtained during the investigation revealed that on multiple occasions the administrator left the facility prior to staff arriving, therefore, leaving residents without any staff to provide care and supervision. The telephone number on the text messages was confirmed to be associated to the facility and the administrator’s personal cell phone number.

This deficiency was cited in an LIC 9099D form, an immediate $500 civil penalty was assessed in an LIC 421IM form, and plan of correction was jointly formulated with Emily Purvis.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
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 5
Control Number 08-AS-20240523164416
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: STAR RESIDENTIAL
FACILITY NUMBER: 374602372
VISIT DATE: 11/25/2024
NARRATIVE
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An exit interview was conducted with Purvis, to whom a copy of this report, LIC 9099D, LIC 421IM, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20240523164416
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: STAR RESIDENTIAL
FACILITY NUMBER: 374602372
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2024
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidenced by:
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Administrative Assistant agreed to schedule basic services/ Care and Supervision training to all staff, by 11/26/2024.
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Based on review of records, the licensee did not ensure there was a staff at the facility to provide care and supervision, which posed an immediate health, safety, and personal rights risk to all residents in care.
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Adminitrative Assistant agreed to submit training certiicates to the LPA, by 12/06/2024.
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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: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/23/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240523164416

FACILITY NAME:STAR RESIDENTIALFACILITY NUMBER:
374602372
ADMINISTRATOR:ALBERT SOUZAFACILITY TYPE:
740
ADDRESS:4469 ROBBINS STREETTELEPHONE:
(858) 622-1933
CITY:SAN DIEGOSTATE: CAZIP CODE:
92122
CAPACITY:6CENSUS: 3DATE:
11/25/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrative Assistant Emily PurvisTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Resident's medication was not stored in the original container
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez conducted an unannounced complaint visit, and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Administrative Assistant Emily Purvis.

It was alleged resident's medication was not stored in the original container. On 05/23/2024, it was reported to the Department staff combined multiple medications in one unlabeled container. During the investigation, interviews with external sources and staff did not reveal any concerns with how medication was stored. Additionally, during multiple visits to the facility, the LPA reviewed residents’ medication lists and the centrally stored medications. There were no unlabeled medication containers, nor combined medications.

Based on the evidence obtained, there was not enough evidence to prove the alleged violation occurred, therefore, the allegation was Unsubstantiated.
(See the 9099C for continuation of report.)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240523164416
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: STAR RESIDENTIAL
FACILITY NUMBER: 374602372
VISIT DATE: 11/25/2024
NARRATIVE
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An exit interview was conducted with Emily Purvis, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5