486801846-4-27-2023-21-AS-FSAI-CRARG6-20230427130014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801846
Report Date: 04/27/2023
Date Signed: 04/27/2023 01:00:48 PM

Document Has Been Signed on 04/27/2023 01:00 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: 2	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee/Administrator Estrella Valendo		TIME COMPLETED:	01:30 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), Farhaan Sarangi arrived unannounced at Golden Star Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Licensee/Administrator Estrella Valendo, and was granted access into the facility. LPA toured the facility. LPA observed the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Emergency Generator was observed in the garage. Water temperature in residents bathroom measured at 111 degrees, within acceptable range of 105 to 120 degrees F. Water temperature in the staff bathroom also measured at 111 degrees and is within acceptable range of 105 to 120 degrees. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Medication Assessment Record (MAR) was also observed. First Aid kit was inspected and found to be appropriate during the inspection. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. LPA discussed the Infection Control Plan with the Licensee. LPA discussed the Emergency Disaster Plan with the Licensee and learned during interviews with both staff members that the Emergency Disaster Drill was last conducted on December 2022, but no documentation was retained in the Emergency Disaster Drill file. (See LIC 809D). (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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: 04/27/2023

NARRATIVE

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LPA educated on the importance of conducting Emergency Disaster Drills quarterly and retaining evidence of that in the Emergency Disaster Plan documents. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE which is stored in the entrance of the facility and observed to be sufficient at this time.

During the Required 1 year inspection, LPA reviewed 2 of 2 resident files and found those files to be appropriate during the inspection. LPA interviewed 2 of 2 residents. LPA reviewed 2 of 2 staff member files and learned that both staff members do not have sufficient training hours (See LIC 9102-Technical Advisories). LPA interviewed 2 of 2 staff members.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents
Evidence of the next Emergency Disaster drill

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeated deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given along with this report.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2023 01:00 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: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews with both staff members, LPA learned that the licensee did not comply with the section cited above due to the facility not conducting an Emergency Disaster Drill this year. This regulation poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Licensee shall submit a Plan of Correction that will include a date for the next Emergency Diaster Drill, retain documentation and provide a statement on how future compliance will be met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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