486801846-4-22-2022-21-AS-KWAS-CDQR3Y-20220422124044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801846
Report Date: 04/22/2022
Date Signed: 04/22/2022 12:42:12 PM

Document Has Been Signed on 04/22/2022 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Estrella Valendo		TIME COMPLETED:	12:50 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	Licensing Program Analyst (LPA) Walters arrived unannounced for the purpose of conducting a Required 1 Year annual inspection. LPA met with Licensee/Administrator, Estrella Valendo and Acting Administrator, Normita Subalo. This visit will focus on the infection control of this facility. LPA signed into using facility sign in sheet, screening questions were posted next to the sign in sheet. Hand sanitizer and disposable face mask were made available. There were two staff present who were providing care and supervision for 1 resident. Neither staff were wearing face coverings. LPA and EV discussed the importance of wearing mask. LPA toured the facility with EV and observed that the facility was clean and a comfortable temperature. Bathrooms were stocked with paper towel and hand washing supplies. There was a 30 day supply of PPE and incontinence products. LPA reviewed resident and staff vaccination records. Staff have received infection control and PPE training through Local Public Health. Training's were documented. Smoke detectors and Carbon Monoxide detectors were tested and appeared to be in working order. Fire Extinguishers were last serviced 03/30/2022. In review of R1's medication, LPA found 2 medication errors, in which the facility failed to issue resident R1's medication. (pictures taken) LPA also learned that there were two other individuals I1 and I2 residing the facility who were not fingerprint cleared or associated. Per Administrator neither individual are working with the resident in care. Continued on LIC 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN STAR HOME	FACILITY NUMBER: 486801846
	VISIT DATE: 04/22/2022

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The facility previously submitted a mitigation plan that was approved by Community Care Licensing, but since then there have been updated regulatory requirements related to infection control prevention and mitigation for communicable diseases. LPA is requesting that the facility submits an updated mitigation plan by 6/30/22. LPA and EV discussed new requirements in PIN 22-13 ASC.

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. This report was read and discussed with Esther Penaflor Appeal rights were provided.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2022 12:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN STAR HOME	FACILITY NUMBER: 486801846
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c.. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's inspection and review of The Guardian, the licensee did not comply with the section cited above in 2 out of 2 individuals residing in the home did not have the proper fingerprint transfer association to this facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2022
	Plan of Correction
1 2 3 4	Facility agrees to submit the required paperwork to CCL to associate both individual to facility. POC due date 4/25/2022. Administrator/Licensee to ensure that all staff have criminal record clearance with DOJ & FBI & are associated to the facility prior to residing or working in the facility.

Type A

Section Cited

CCR

87465(a)(5)

87465 (a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. Facility staff failed to give residents' their medications as ordered/prescribed by the Physician. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review and interviews R1 missed two dosages of medication which poses an immediate risk to the health and safety of residents in care.
	POC Due Date: 04/27/2022
	Plan of Correction
1 2 3 4	Adminstrator will audit all resident's medication and update resident's centrally stored logs and ensure staff are properly distrubuting medication. Facility to send LPA copy of updated centrally stored log, that includes start dates of medication by POC due date 4/27/22.

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: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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