392700463-10-13-2022-27-AS-APAA-CK6U8T-20221013152200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700463
Report Date: 10/13/2022
Date Signed: 10/13/2022 03:22:04 PM

Document Has Been Signed on 10/13/2022 03:22 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 HOME		FACILITY NUMBER:	392700463
ADMINISTRATOR:	ARROYO, MONICA		FACILITY TYPE:	735
ADDRESS:	2045 GIBSON CT		TELEPHONE:	(510) 754-8833
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	6	CENSUS: 5	DATE:	10/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Monica Arroyo		TIME COMPLETED:	12:30 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	On 10/13/2022 at 10:30am, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual infection control visit. LPA Pascua was greeted by Administrator, Monica Arroyo and explained the purpose of the visit. The purpose of the visit is to conduct an annual infection control visit. This facility is licensed to hold 6 ambulatory residents and is vendorized by Valley Mountain Regional Center to hold Level 4I residents at this time. The current census was 5. There was two other staff members at the time of this visit, Colleen Garcia and Lourdes Jimenez. Administrator holds a current Administrator certificate #6044527735 and is valid until 11/06/2023. At 10:40am, LPA Pascua initiated a tour with Administrator Arroyo. At 10:45am, The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair. At 10:50am, A tour of the kitchen was conducted. LPA Pascua observed a sufficient amount of 2-day perishable food supply in the refrigerator and a 7-day non-perishable food supply in the pantry for 5 residents. Knives were observed to be locked and made inaccessible to the residents at this time. Cleaning supplies were also observed to be locked under the kitchen sink and made inaccessible to the residents in care. A fire extinguisher was also observed to be in the kitchen and was annually inspected by Nor Cal Fire on 10/13/2022. From 10:55-11:05am, LPA Pascua observed a locked centralized stored medication cabinet located in a locked closet under the stairs. Along with the Administrator Arroyo, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. At 11:10am, LPA Pascua toured the garage. Additional food supply was identified in the refrigerator located in the garage. Additional toiletries were also identified. At 11:15am, LPA Pascua toured bathroom #1 and was observed to be in good repair. Hot water temperature was measured to be 106 degrees.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: STARFLOWER CARE HOME	FACILITY NUMBER: 392700463
	VISIT DATE: 10/13/2022

NARRATIVE

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At 11:20am-11:50am, LPA Pascua toured 6 resident bedrooms. Resident furniture was observed to be sufficient to meet their needs at this time. 1 staff bedroom and 1 bathroom was also toured.
At 11:50am, LPA Pascua toured a second resident bathroom. Hot water temperature was measured to be 112 degrees.
At 11:55am, LPA Pascua toured the laundry room. A washer and dryer to wash residents bedding and clothing was identified. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Administrator, Monica Arroyo.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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