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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801846
Report Date: 06/23/2021
Date Signed: 09/16/2021 04:30:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:GOLDEN STAR HOMEFACILITY NUMBER:
486801846
ADMINISTRATOR:VALENDO, ESTRELLAFACILITY TYPE:
740
ADDRESS:672 RUBIER WAYTELEPHONE:
(707) 374-4087
CITY:RIO VISTASTATE: CAZIP CODE:
94571
CAPACITY:6CENSUS: DATE:
06/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Estrella Veranda, LicenseeTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPAs) Katrina Walters and Jill Nakagawa arrived unannounced and conducted case management visit. LPA was greeted by staff. Administrator, Estrella Valendo arrived later. There are currently 3 residents all of which have a dementia diagnosis and two of those residents are on hospice.

During a complaint visit on 6/23/21 LPAs Katrina Walters and Jill Nakagawa observed that furniture was being used to obstruct the walkway from the bedroom hallway to the kitchen. Per the Administrator they were using the furniture to prevent resident R1 from entering the dinning room and exiting the facility. Administrator and staff then immediately moved the table so that it would not obstruct access to the rest of the facility.

Resident 2 (R2) had been observed on an earlier visit with a chair next to their bed preventing them from getting up. Interviews reveal that staff place the chair in front of the resident's bed to prevent them from falling out of bed. LPA discussed with Administrator that a chair cannot be used in exchange of supervision. Administrator stated they understood. LPA was unable to cite during the previous visit.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Estrella Valendo, Licensee/Administrator, who's signature below confirms receipt of report.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2021
Section Cited

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87464 Basic Services Basic services shall at a minimum include: (1) Care & supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as
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evidenced by: Based on observation and interviews, the licensee did not provide care and supervision for R2.which posed an immediate risk to health and safety.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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