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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701183
Report Date: 10/08/2024
Date Signed: 10/08/2024 04:46:55 PM

Document Has Been Signed on 10/08/2024 04:46 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
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: 6DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 10/8/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required one year annual inspection. LPA Jensen met with Administrator Arlene Acuavera and Co-Administrator Romel Acuavera and explained the purpose of today's visit.

LPA Jensen inspected the grounds. The front yard has a full gate. All paths were free of obstruction. There are no bodies of water. The window screens are in good repair. The fence was observed to leaning. There was also various pieces of wood along the fence where repairs had previously been attempted. The backyard fence is now in need of replacement. There are shaded areas available for outdoor activities. LPA Jensen toured the interior and observed the facility to be sanitary. There was adequate furnishings throughout the common areas. The facility maintains in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. The food in the freezer was not labeled. Technical assistance was provided. There are fresh fruits and vegetables available. Dinner was being prepared and consisted of mashed potatoes, meat loaf, carrots and fruit salad. There was a variety of snacks and beverages available. The fire extinguisher was last serviced on 11/27/23 and is in compliance. The carbon monoxide detector was tested and found to be in good working order. There are flash lights available for emergency use. The water temperature was within the required range. The thermostat was set at 73 degrees for the comfort of the residents.

The facility is licensed for 4 non-ambulatory residents and 2 ambulatory residents. LPA Jensen reviewed the facility sketch, the fire clearance and the resident roster. It was learned that resident 6 (R6) is non-ambulatory but occupying an ambulatory room. It was also learned through a resident file review that Resident 2, who occupies a non-ambulatory room, has a restricted health condition care plan (RHCCP) dated 11/1/23 that states R2 "is unable to to turn/reposition without assistance from staff". The LIC 602 is dated 12/27/22 and states R2 is non-ambulatory. The Licensee has agreed to obtain a new LIC 602 to verify the ambulatory status of R2 and submit to the department.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: STAR BLOOM CAREHOME
FACILITY NUMBER: 392701183
VISIT DATE: 10/08/2024
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The liability insurance was reviewed and is current. LPA Jensen obtained a copy of the LIC 500. Staff files were reviewed and observed to be complete. Resident files were reviewed and observed to be complete.
LPA Jensen interviewed residents and clients.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Civil penalties are also being assessed. An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2024 04:46 PM - It Cannot Be Edited


Created By: Maja Jensen On 10/08/2024 at 04:36 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STAR BLOOM CAREHOME
FACILITY NUMBER: 392701183

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Jensen's review of the facility sketch, fire clearance and LIC 602, R2 is non-mbualtory and occupying a designated ambulatory room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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Licensee will send a revised facility sketch to LPA by email and LPA with submit an STD 850 to request the addition of another non-ambulatory room.
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:Lisa Rios
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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