392701183-6-26-2026-27-AS-NWPN-DV3VNW-20260615163550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701183
Report Date: 06/15/2026
Date Signed: 06/26/2026 11:47:03 AM

Document Has Been Signed on 06/26/2026 11:47 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 CAREHOME		FACILITY NUMBER:	392701183
ADMINISTRATOR/ DIRECTOR:	ACUAVERA, ARLENE		FACILITY TYPE:	735
ADDRESS:	2410 LAGUNA CT		TELEPHONE:	(209) 641-9320
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6		CENSUS: 5	DATE:	06/15/2026
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Arlene Acuavera		TIME VISIT/ INSPECTION COMPLETED:	02:31 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	This report was amended to correctly identify Anna Simms as a representative of VMRC, and add titles to Brian Bennet and Anna Simms On 6/15/26 a non compliance conference was held via Microsoft Teams. The purpose of the NCC was to discuss the complaints since licensure. Present at today’s NCC were the Sacramento South Regional Office Adult and Senior Staff, Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Noel WolfPetersen, Valley Mountain Regional Representatives Director of Community Services Brian Bennet and Quality Assurance Program Manager Anna Simms, as well as Licensee and Administrator (LIC/ADM) Arlene Acuavera. The meeting begain at 1:30 pm. Upon review of a departmental report in a case mangement 5/20/26 it was substantiated that a lack of care and supervision 80078(a) had the effect of delayed medical attention to a client in the care of the facility. Licensee expressed that she did not agree with the specific timeline of the incident as outlined by the department or that neglect precipitated or exacerbated the event, but did agree that untimely medical attention was the result. The administrator's account provided that in November of 2025 a client was expressing pain on the morning of 17th and received medical attention on the evening of the 18th. The recent incident was discussed in the context of preventing a potential similar incident in the future. Several areas of improvement were identified: the training of the staff in the use of emergency services, the administrators planning for transport needs of the clients, the use of a backup administrator. These areas of improvement should be addressed in ammenda to the plan of operation sent in to the office by 6/29/26, as well as copies of LIC 500's showing administrator hours for both facilities and LIC 308's designating a backup administrator. The VMRC representatives asked for an updated organizational chart. continued on c page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026

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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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: 06/15/2026

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The department expressed its interest in the administrators willingness to provide plans and resources to the staff that do not overlap with plans and resources made available so far.

The offer of a referral to Technical Support Program was accepted by the licensee.

The meeting was concluded at 2:31 pm. A copy of the report and the 9111 was read and given to the licensee. exit interview contacted, appeal rights provided. The licensee was informed that participating in the meeting does not alleviate the department from taking other administrative actions. quarterly monitoring will continue until the incident is reviewed and a decision rendered by the legal department.

copy was sent for signature electronically to the email on file for the facility.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026

LIC809 (FAS) - (06/04)

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