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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600340
Report Date: 09/23/2023
Date Signed: 09/23/2023 03:25:59 PM


Document Has Been Signed on 09/23/2023 03:25 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:RJ STARLIGHT HOME CORPORATIONFACILITY NUMBER:
385600340
ADMINISTRATOR:TERESITA JOMOKFACILITY TYPE:
740
ADDRESS:2680 BRYANT STREETTELEPHONE:
(415) 648-2280
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:12CENSUS: 12DATE:
09/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Teresita JomokTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection. LPA Lund met with Staff and explained the reason for the visit. LPA later met Administrator Teresita Jomok. Census 12

LPA Lund Lund & Administrator Teresita Jomok toured/inspected the facility passageways were free of obstruction. There were no bodies of water observed. Resident’s bathroom was equipped with grab bars and non-slip mat for toilet, bathtub, and shower. Disinfectants, cleaning solutions and poisons are locked in cabinet outside in the backyard and inaccessible to clients. LPA observed lighting in all bedrooms. First aid kit was complete. Smoke detectors and Carbon Monoxide were present throughout the facility. Fire extinguisher was last serviced April 13, 2023. LPA observed nonperishable foods for a minimum of (1) one week and fresh perishable foods for a minimum of (2) two days. Centrally stored medication was locked in the kitchen cabinet and inaccessible to residents.

LPA reviewed staff and residents’ records. Residents (R1 through R4) do not have 12- month reappraisals.

Deficiencies was observed and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit Interview and a copy of this report and appeal rights were left with Administrator, Teresita Jomok.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2023
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 09/23/2023 03:25 PM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: RJ STARLIGHT HOME CORPORATION
FACILITY NUMBER: 385600340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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Administrator Teresita Jomok will go over residents files and up date resident's files and email LPA Lund stating she has updated the records.
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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2