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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
486801846
Report Date:
04/15/2024
Date Signed:
04/15/2024 11:37:37 AM
Document Has Been Signed on
04/15/2024 11:37 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO
,
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:
3
DATE:
04/15/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:10 AM
MET WITH:
Normita Subala
TIME COMPLETED:
11:45 AM
NARRATIVE
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LPA Hiratsuka conducted this unannounced annual visit.
LPA toured the facility with Caregiver Normita Subala. The facility has locked cabinets for medications and cleaning chemicals. Each room has an exit to the outside. There is an ample supply of perishable and nonperishable food. Staff have the required training.
The following was observed during today's visit:
-The front door has a latch that connects the frame to the front door and has a key to lock the latch. This is not allowed because it is not part of the door knob. This prevents residents from going out the front door.
-The front and back door has a latch that is not part of the original lock on the door. The latch is attached to the door frame and is pushed up and the over to cover part of the door and pushed down preventing people from getting out.
-the front door audio alert was turned off. This is required when having residents who have wandering behaviors
-two of the three resident records have a diagnosis of dementia and their physician's reports are over 12 months old. Per Title 22 regulations someone with a diagnosis of dementia shall have an updated physician's report every 12 months.
Today, LPA advised Caregiver that medications shall be prepared each time they are required to be given. Prepouring medication is not allowed
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
04/15/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
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Document Has Been Signed on
04/15/2024 11:37 AM
- 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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
GOLDEN STAR HOME
FACILITY NUMBER:
486801846
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/15/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because the front door has a latch that is attached to the door frame and extends over the door and has key that requires it to be opened. The front and back door both have a latch that is attached to the door frame and when pushed up is able to cover part of the front door and then pushed down which locks it in place but does not require a lock. Both prevents residents from exiting which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/16/2024
Plan of Correction
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By 04/16/2024, the licensee shall remove the lock and latches from the doors and submit proof to Community Care Licensing Division along with a written statement stating how they shall prevent it from occuring again.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because the front door's audio alarm is turned off which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/16/2024
Plan of Correction
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Licensee shall submit a written plan of correction on how they shall ensure audio alerts are turned on and how they shall monitor the audio alerts.
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
04/15/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/15/2024
LIC809
(FAS) - (06/04)
Page:
2
of
4
Document Has Been Signed on
04/15/2024 11:37 AM
- 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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
GOLDEN STAR HOME
FACILITY NUMBER:
486801846
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/15/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/15/2024
Plan of Correction
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By 05/15/2024, Licensee shall submit a written plan of correction on how they shall ensure people who have a diagnosis of dementia shall have an annual medical assessment.
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.
This requirement is not met as evidenced by:
Deficient Practice Statement
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cited in error
POC Due Date:
04/15/2024
Plan of Correction
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cited in error. no deficency
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:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
04/15/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/15/2024
LIC809
(FAS) - (06/04)
Page:
3
of
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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
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
GOLDEN STAR HOME
FACILITY NUMBER:
486801846
VISIT DATE:
04/15/2024
NARRATIVE
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The following shall be updated and submitted to Community Care Licensing Division by 04/30/2024:
-LIC 400 Affidavit Regarding Client/Case Resources
-if the facility is handling resident monies, the facility shall obtain a surety bond and submit a copy to Community Care Licensing Division. If the facility is not handling resident monies a surety bond is not required.
-liability insurance
-LIC 500 facility personnel or staff schedule
-copy of current administrator certificate.
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. Appeal rights were provided.
SUPERVISOR'S NAME:
Troy Ordonez
TELEPHONE:
(916) 263-4832
LICENSING EVALUATOR NAME:
Kerry Hiratsuka
TELEPHONE:
(916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE:
04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/15/2024
LIC809
(FAS) - (06/04)
Page:
4
of
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