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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600076
Report Date: 01/05/2026
Date Signed: 01/05/2026 02:55:37 PM

Document Has Been Signed on 01/05/2026 02:55 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:STELLA'S CARE HOME IFACILITY NUMBER:
385600076
ADMINISTRATOR/
DIRECTOR:		MARGIE VALERIAFACILITY TYPE:
740
ADDRESS:616 39TH AVENUETELEPHONE:
(415) 752-8652
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY: 12CENSUS: 10DATE:
01/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:24 AM
MET WITH:Fernando Inducta, Caregiver/House Manager and Henry Chang, Licensee's Husband TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 1/5/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the 1-year required Annual Inspection. LPA Calandra was greeted by Fernando Induct, Caregiver/temporary House Manager and explained the purpose of the visit. Licensee's Husband, Henry Chang arrived later during the visit.

LPA toured the physical plant. This is a 2-story house with 7 bedrooms, 4 bathrooms, a kitchen, office, living room, dining room, garage, and Foyer. All bedrooms had the required furniture and sufficient lighting. All bathrooms had the required non-skid flooring and grab bars. The facility's fire alarm was observed to be in working order. The facility's fire extinguishers were observed to be fully charged and last checked on 10/29/2025 . The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's first aid kit had the required items.

LPA reviewed 5 resident files and 6 staff files. During record review, missing documents were observed.

This facility does not handle cash resources for residents.

A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 13
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 13
Document Has Been Signed on 01/05/2026 02:55 PM - It Cannot Be Edited


Created By: John Calandra On 01/05/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure that disinfectants, cleaning solution, and poisonous susbtances such as bleach were locked and in-accessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Licensee will lock up soap, detergent, poisons, and cleaning solutions by the POC due date.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure that knives, and sharp objects(scissors) were locked up and in-accessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Licensee will place knives in a secured area temporarily until a lock can be placed on the knives drawer in the kitchen.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 01/05/2026 02:55 PM - It Cannot Be Edited


Created By: John Calandra On 01/05/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not ensure that S1 had taken a TB exam prior to employment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Licensee will send S1 to get TB tested and send results to the Department.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 01/05/2026 02:55 PM - It Cannot Be Edited


Created By: John Calandra On 01/05/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee has Liability insurance but could not provide proof of coverage during the Annual Inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Licensee will provide proof of active liability insurance policy by the POC due date.
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee does have a Carbon Monoxide detector but was unsure where it was located, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Licensee will provide proof of Carbon Monoxide detector to the Department by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 01/05/2026 02:55 PM - It Cannot Be Edited


Created By: John Calandra On 01/05/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure that faucets delivered hot water between the temperatures of 105-120, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Licensee will adjust hot water temperature and send proof to the Department that Hot water temperature is between 105-120 degrees Fahrenheit.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not ensure that faucets in the upstairs were functioning properly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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4
Licensee will contact a plumber to fix the faucets upstairs and send proof of correction to the Department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 01/05/2026 02:55 PM - It Cannot Be Edited


Created By: John Calandra On 01/05/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on record review, the licensee hired someone to do a CPR and First Aid training but no proof of the training(CPR and First Aid Certificates) could be found during the Annual Inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
1
2
3
4
Licensee will send CPR and First Aid training certificates to the Department by the POC due date.
Type B
Section Cited
CCR
87412(c)(2)(D)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on record review, the licensee has conducted trainings on subjects such as locking of medications and Dementia but did not document the number of training hours per subject, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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2
3
4
Licensee will provide documentation of number training hours per subject.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 01/05/2026 02:55 PM - It Cannot Be Edited


Created By: John Calandra On 01/05/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not conduct 8 hours of Dementia Care training and four hours of training which shall be specific to postural supports, restricted health conditions, and hospice care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
1
2
3
4
Licensee will send list of atendees, subjects of trainings, and number of hours of trainings to the Department by the POC due date.
Type B
Section Cited
CCR
87555(b)(25)
General Food Service Requirements
(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not ensure that food supplies and soap, detergents, and cleaning compounds are stored separately, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
1
2
3
4
Licensee will ensure that food supplies and soap, detergents, and cleaning compounds are stored separately and send POC to the Department by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 8 of 13
Document Has Been Signed on 01/05/2026 02:55 PM - It Cannot Be Edited


Created By: John Calandra On 01/05/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(2)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not record date and time of each contact with the physician, the physician's directions when assisting residents with self-administration of PRNs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
1
2
3
4
Licensee will create a log and begin documentation. Licensee will also conduct a training to ensure compliance.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not ensure that the date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
1
2
3
4
Licensee will create a document to record date and time of PRN medication taken, dosage, and resident response and provide staff training to ensure future compliance.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 9 of 13
Document Has Been Signed on 01/05/2026 02:55 PM - It Cannot Be Edited


Created By: John Calandra On 01/05/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not ensure that R1 and R2 had Pre-Admission Appraisals completed prior to admission, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
1
2
3
4
Licensee will create a Plan of Correction to ensure that this violation does not occur again and submit it to the Department by the POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not ensure that quarterly emergency drills were conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Licensee will conduct an emergency drill and send proof of quarterly emergency drills to the Department throughout the year.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 10 of 13
Document Has Been Signed on 01/05/2026 02:55 PM - It Cannot Be Edited


Created By: John Calandra On 01/05/2026 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not ensure that an Appraisal of resident needs and services plan for R3 had been completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Licensee will ensure that an Appraisal of Needs and Services for R3 is created and will send POC to the Department by the due date listed above.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 11 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076
VISIT DATE: 01/05/2026
NARRATIVE
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During the tour of the physical plant, LPA observed that soap, detergent, poisons, and sharp objects such as knives and scissors were not locked up and in-accessible to persons in care. A Type A citation was issued for not ensuring that sharp objects were locked up. A Type A citation was also provided for not ensuring soap, detergent, and poisons were locked up and in-accessible to persons in care.

During record review of staff files, LPA observed that S1 did not have a TB exam prior to employment. A Type B citation was provided for this deficiency.

In addition, LPA asked for a copy of the Licensee's Liability Insurance but one could not be provided during the inspection. A Type B citation was provided for this deficiency.

During the tour of the physical plant, LPA could not locate the facility's carbon monoxide detector. LPA asked Licensee but they could not locate it. A Type B citation was provided for this deficiency.

In addition, during the tour of the physical plant, LPA observed that the facility's faucets in bathrooms did not deliver hot water between the required temperature of 105-120 and were not in good repair. Two Type B citations were issued for these deficiencies.

During record review, LPA observed that the Licensee had not documented the number of hours of trainings on subjects such as Dementia. In addition, LPA observed that none of the staff had active CPR and First Aid Training. Per conversation with the Licensee, a CPR and First Aid training had been conducted recently but the active certificates for staff could not be located at the time of the inspection. Type B citations were issued for these deficiencies.

In addition, during record review, LPA observed that Licensee had not provided 8 hours of Dementia care training and four hours of training which shall be specific to postural supports, hospice care, and restricted health conditions. A Type B citation was provided for this deficiency.

During the tour of the physical plant, LPA observed that Licensee was storing food supplies with soap, detergent, and poisons. A Type B citation was provided for this deficiency.


NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
LIC809 (FAS) - (06/04)
Page: 12 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076
VISIT DATE: 01/05/2026
NARRATIVE
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During record review, LPA observed that Licensee had not recorded the date and time of each contact with physicians and the physicians directions when assisting residents with self-administration of PRNs. A Type B citation was provided for this deficiency.

In addition, during record review, LPA observed that the Licensee had not ensured that the date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

During record review, LPA observed that Pre-Admission appraisals had not been completed for R1 and R2 prior to admission. A Type B citation was provided for this deficiency.

During record review, LPA observed that Licensee did not ensure that quarterly emergency drills were completed. A Type B citation was issued for this deficiency.

In addition, during record review, LPA observed that R3 was missing an Appraisal of Needs and Services. A Type B citation was provided for this deficiency.

LPA requested the following documents be sent to the Department by 1/16/2026:
- Control of Property(Property tax statement or Deed)
- Current Liability Insurance
- Up to date LIC 500(Personnel Summary Report)
- Administrator's Certificate

Deficiencies are cited under the California Code of Regulations. Failure to correct the deficiencies by the POC due date may result in Civil Penalties.

An exit interview was conducted. This report was reviewed with facility representative and a copy of the report along with Appeal Rights provided.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
LIC809 (FAS) - (06/04)
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