486801846-9-16-2021-21-AS-CMAZ-C8WUBR-20211119142644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801846
Report Date: 09/16/2021
Date Signed: 09/16/2021 05:10:38 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

PUBLIC

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: 3	DATE:	09/16/2021
		UNANNOUNCED	TIME BEGAN:	02:57 PM
MET WITH:	Estrella Valendo		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Facility is serving expired food.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of delivering findings regarding the allegation listed above. LPA met with Administrator/Licensee, Estrella Valendo (EV). Assistant Administrator, Normita Subala arrived later.

During investigation LPA interviewed staff, residents and various outside parties, LPA conducted virtual and in-person visits to the facility on 03/19/21 and on 06/24/21, made observations and took pictures.

The complainant alleged that the faciltiy is serving expired food to residents. Based on interviews and observations LPA learned the following: On 3/19/21, LPA toured the facility virtually with EV and NS. LPA observed expired can foods dated 2018 in the garage and expired decayed food in the fridge. (pictures taken) LPA asked that EV remove all expired food from the refrigerator and throw away expired canned foods. Interviews confirmed that food was being given to residents.
Continued onto 9099 C

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: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/16/2021 Section Cited CCR 87555(b)(8)	1 2 3 4 5 6 7	87555(b)(8) General Food Service Requirements: (b) The following food service requirements shall apply: (8) All food shall be of good quality. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	LPA asked Licensee to immediately throw away the spoiled food. Staff removed all expired food during facility visit. POC cleared during visit.
	8 9 10 11 12 13 14	Based on observations, Administrator did not ensure the regulation above due to uncovered food, expired fresh food, and canned foods. This a potential health & safety risk to residents 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: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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: 09/16/2021

NARRATIVE

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LPA conducted an additional in-person visit regarding this complaint on 6/24/21 with LPA Jill Nakagawa. LPA observed expired food in kitchen and garage refrigerator. (pictures taken) EV arrived at the facility and greeted LPA's. LPAs and EV then toured the garage again and observed the second Administrator, Jennifer Thein (JT) had entered through the garage and was taking food from the refrigerator. JT stated that they were packing the food for a party. JT stated that the food in that refrigerator was for staff only. LPAs then observed that the food that was previously in that refrigerator had been thrown in the outside garbage. (pictures taken)

During today's visit on 9/16/21, LPA observed expired food in the resident's refrigerator and expired canned goods dated 6/2020 in the garage. Pineapples in the resident's refrigerator was uncovered. Lettuce was brown and sitting in water.

Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The allegations that Facility is serving expired food to residents is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

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