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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701183
Report Date: 05/20/2026
Date Signed: 07/14/2026 08:54:11 AM

Document Has Been Signed on 07/14/2026 08:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STAR BLOOM CAREHOMEFACILITY NUMBER:
392701183
ADMINISTRATOR/
DIRECTOR:		ACUAVERA, ARLENEFACILITY TYPE:
735
ADDRESS:2410 LAGUNA CTTELEPHONE:
(209) 641-9320
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 5DATE:
05/20/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Emilia BaguinonTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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**This report was amended to include language for the further review of H&S 1548.**
Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to deliver findings of a department report investigating a complaint with the allegation of staff did not prevent a resident from sustaining a fracture while in care found to be unsubstantiated after investigation. LPA met with Emila Baguinon, designated representative of Starbloom Care Home via a LIC 308 to explain the purpose of the visit. The investigative report also concludes that the staff failed to seek timely medical attention for the resident.
In interviews, 3 staff and the administrator noticed the resident expressing pain related to their arm on 11/17/2025. The administrator asked staff to monitor and communicate if there was a bruise or swelling. Two staff reportedly noticed a bruise on 11/18/2025, when asked about the size of the bruise, the administrator gave a statement, "the bruise covered the upper area of the arm near the shoulder and it appeared swollen." The administrator asked staff to apply ice to the affected area. On 11/19/2025, the administrator arrived in the early afternoon, made an observation of the bruise, asked staff to apply ice, and told staff she would return later in the afternoon to take the client to the hospital. The resident was brought to the emergency room on 11/19/2025 around 9pm, consultation was dated 11/19/2025 11:57 pst.
Based on the departments observations, interviews, and record review(s),
The following deficiencies were observed (see 809-D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1548 H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.
A copy of the report was read and given to the administrator/designated representative. A citation of this type, meets the criteria for a 500$ immediate civil penalty attached on a following LIC 421IM.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2026
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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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)
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Document Has Been Signed on 05/20/2026 11:11 AM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 05/20/2026 at 09:40 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STAR BLOOM CAREHOME
FACILITY NUMBER: 392701183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2026
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not followed, as evidenced by:
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LPA suggested Create/update a procedure for calling 911 and nonemergency transportation, provide training and signage for staff. Representative agreed to: there is a template procedure on the wall near the phone how to call 911, There will be a training about the template and how to use it, and it will be sent to the LPA. 5/21/26. noel.wolfpetersen@dss.ca.gov.
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 interviews with 2 staff and 1 administrator where a client was expressing an injury (bruising, swelling, pain and guarding) and not having arrangements for or provision of transport to a higher level of medical intervention for 24+ hours. Interview with administrator where opportunities to provide transport to a higher level of medical intervention, EMS or facility transport, were dismissed for unclear reasons.

Not following this requirement poses a concern for the health, safety and personal rights of clients in care.
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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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2026


LIC809 (FAS) - (06/04)
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