374603625-11-21-2024-08-AS-RHAL-DB8SRA-20241121130601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603625
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:07:35 PM

Document Has Been Signed on 11/21/2024 01:07 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	STELLAR CARE		FACILITY NUMBER:	374603625
ADMINISTRATOR/ DIRECTOR:	BRANDON CHO		FACILITY TYPE:	740
ADDRESS:	4518 54TH STREET		TELEPHONE:	(619) 287-2920
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92115
CAPACITY: 120	TOTAL ENROLLED CHILDREN: 0	CENSUS: 106	DATE:	11/21/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:28 AM
MET WITH:	Brandon Cho, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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	Licensing Program Analyst (LPA) Renita Hall conducted an unannounced case management visit to follow up on an incident reported to Community Care Licensing. LPA met with Brandon Cho, Executive Director, and discussed the purpose of the visit. On November 20, 2024, the facility updated the death report of Resident 1 (R1), age 99, to the Community Care Licensing Division (CCLD). The death occurred at the hospital post-acute skilled nursing facility (SNF), after hip surgery. The updated report included the cause of death that was not available to the facility at the time of death from the hospital on November 10, 2024. According to the facility’s written incident report, R1 experienced an unwitnessed fall on October 30, 2024, at approximately 4:42 am. R1 was transported to the hospital for medical treatment and underwent hip surgery on October 30, 2024. The facility reported that R1 passed away on November 10, 2024, the principal causes of death were Failure to Thrive, advanced dementia, and cerebrovascular accident (CVA); contributory causes were a recent hip fracture and chronic AFB according to the Death Record from the hospital. The facility was notified of the death from the Power of Attorney (POA) on November 11, 2024. .

Denise Powell	TELEPHONE: (619) -76-2317
Renita Hall	TELEPHONE: (619) 767-2301
	DATE: 11/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: STELLAR CARE	FACILITY NUMBER: 374603625
	VISIT DATE: 11/21/2024

NARRATIVE

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The Licensing Program Analyst (LPA) interviewed the Administrator and staff regarding the incident. The Administrator stated that staff followed the facility’s emergency protocols and contacted emergency services. Staff present during the incident confirmed that R1 was monitored per their care plan before the event.

Review of Records: R1’s medical records indicated the resident was receiving physical therapy once a week for 5 weeks to address muscle weakness and balance disturbance having difficulty with standing. The primary diagnosis was Dementia, secondary diagnosis: was falls, neuropathy, AFB, and insomnia. R1 needed a wheelchair and was considered non-ambulatory per the signed LIC602A. The facility’s incident reports were submitted within the required timeframe and included all pertinent details. Observations of the facility revealed appropriate safety measures were in place; no environmental hazards were observed.

Based on the information gathered, the facility appears to have acted appropriately and in compliance with applicable regulations regarding this incident. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the Executive Director along with appeal rights (LIC9058 03/22) and an LIC 811

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita Hall	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC809 (FAS) - (06/04)

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