486801846-11-8-2021-21-AS-CMAZ-C8WUBQ-20211119142644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801846
Report Date: 11/08/2021
Date Signed: 11/08/2021 01:46:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2021 and conducted by Evaluator Katrina Walters

COMPLAINT CONTROL NUMBER: 21-AS-20210315115338

FACILITY NAME:	GOLDEN STAR HOME		FACILITY NUMBER:	486801846
ADMINISTRATOR:	VALENDO, ESTRELLA		FACILITY TYPE:	740
ADDRESS:	672 RUBIER WAY		TELEPHONE:	(707) 374-4087
CITY:	RIO VISTA	STATE: CA	ZIP CODE:	94571
CAPACITY:	6	CENSUS: 1	DATE:	11/08/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Licensee, Estrella Valendo		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff threatened resident.
Resident's diapering needs are not being met resulting in resident's sustaining a Urinary Tract Infection.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Walters arrived unannounced to deliver findings regarding the above-mentioned complaint allegations and met with Administrator, Normita Subala (NS) and Licensee, Estrella Valendo (EV).

During investigation LPA interviewed staff, residents, responsible parties and various outside parties, LPA conducted virtual and in-person visits to the facility on 03/19/21, 06/23/21 and on 09/19/21 made observations, reviewed resident records and took pictures.

The complainant alleged that facility staff threatened resident. LPA interviewed staff, responsible parties and residents, and Statements. Based on the information received, there is no evidence to support that staff threatened any of the residents.

Continued on LIC 809 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210315115338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/08/2021

NARRATIVE

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Continued from LIC 809

The complainant also alleged that Resident's diapering needs are not being met resulting in resident's sustaining a Urinary Tract Infection. LPA toured the facility and observed that the facility has had a sufficient supply of incontinence products for all residents. Hospice and caregiver charting notes did not indicate that any of the residents had urinary tract infections.

Based on the statements received, observations made and documents reviewed, A finding that the complaint allegations: Staff threatened resident and Resident's diapering needs are not being met resulting in resident's sustaining a Urinary Tract Infection are UNSUBSTANTIATED meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred. We have therefore dismissed the complaint.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC9099 (FAS) - (06/04)

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