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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700463
Report Date: 09/20/2021
Date Signed: 09/20/2021 04:32:34 PM

Document Has Been Signed on 09/20/2021 04:32 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:STARFLOWER CARE HOMEFACILITY NUMBER:
392700463
ADMINISTRATOR:ARROYO, MONICAFACILITY TYPE:
735
ADDRESS:2045 GIBSON CTTELEPHONE:
(510) 754-8833
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 6CENSUS: 4DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Monica Arroyo, AdministratorTIME COMPLETED:
12:36 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by caregiver, Janessa Morgan S1. LPA met with Monica Arroyo, Administrator AD.

LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 105.1 degrees in residents bathroom with the S1 which is in required range of 105 to 120 degrees.
Last Fire Drill conduced dated 6/16/21. Fire extinguisher maintained 1/17/2021.
Fire alarms in all rooms. Carbon monoxide in main hallway leading to kitchen.
LPA and AD observed centrally stored medications. LPA observed sharps and toxins locked. First aid complete. No obstructions to emergency exit areas.
LPA reviewed 5 staff and 4 resident files. Resident emergency contact complete. LPA observed all staff files complete.
Administrator Certificate valid until 11/6/2021.
All persons in facility fully vaccinated. LPA observed 30 days PPE supply.
Per California Code of Regulations, Title 22 Division 6, Chapter 8, NO deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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