486801846-11-8-2021-21-AS-KMOA-C8W2AF-20211118161327

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801846
Report Date: 11/08/2021
Date Signed: 11/08/2021 02:10:39 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
09/16/2021 and conducted by Evaluator Katrina Walters

COMPLAINT CONTROL NUMBER: 21-AS-20210916092744

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:	DATE:	11/08/2021
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Licensee, Estrella Valendo		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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3
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5
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7
8
9

Faciltiy staff are not repositioning resident
Facility staff failed to performe oral care

INVESTIGATION FINDINGS:

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2
3
4
5
6
7
8
9
10
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12
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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 agencies, made observations, reviewed resident records and took pictures.

The complainant alleged Faciltiy staff are not repositioning resident. LPA received statements from resident's R1 and R2 hospice agency, interviewed staff and made observations. Statments and records reviewed did not reveal that staff failed to reposition residents. Based on documents and statements the allegation is UNSUBSTANTIATED.

The complainant also alleged that Facility staff failed to performe oral care. LPA conducted interviews, made observations of resident. Resident R1 seems to have poor oral health, but LPA is unable to deterimined when this has began. Therefore the based on LPA's observations, documents reviewed and interviews, the allegation is UNSUBSTANTIATED.

A finding that the complaint is unsubstantiated means that although the allegation may have happened there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

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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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
09/16/2021 and conducted by Evaluator Katrina Walters

COMPLAINT CONTROL NUMBER: 21-AS-20210916092744

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:	DATE:	11/08/2021
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Licensee, Estrella Valendo		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Faciltiy failed to provide safe and healthful living accomadations

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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, made observations, reviewed resident records and took pictures. There was an allegation that the faciltiy failed to provide safe and healthful living accomodations, in conducting the investigation LPA witnessed and observed ants on Resident R1’s face, hands and sheets (pictures on file). In addition LPA observed feces covering resident R1's hands(pictures on file) and therefore based on LPA’s own observation the allegation is substantiated. Per EV, staff check residents approximetely every two hours. EV and NS provided LPA with proof of pest control services. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Appeal Rights Given.

Substantiated

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)

Page: 2 of 3

Control Number 21-AS-20210916092744

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/09/2021 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	80072 Personal Rights (a)... residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	Administrator and Licensee provided LPA with proof that they receive pest control services. Deficiency cleared during visit.
	8 9 10 11 12 13 14	Based on observation, Licensee did not ensure the personal rights of persons in care a safe & health accomodations. R1 body covered in ants and feces. which poses/posed an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021

LIC9099 (FAS) - (06/04)

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