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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801846
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:38:21 PM

Document Has Been Signed on 02/19/2025 04:38 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GOLDEN STAR HOMEFACILITY NUMBER:
486801846
ADMINISTRATOR/
DIRECTOR:		VALENDO, ESTRELLAFACILITY TYPE:
740
ADDRESS:672 RUBIER WAYTELEPHONE:
(707) 374-4087
CITY:RIO VISTASTATE: CAZIP CODE:
94571
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
02/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Estrella Valendo, Administraor/LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct an initial 10-day Complaint Investigation Visit and subsequently discovered other unrelated deficiencies resulting in this Case Management - Deficiencies Inspection. The purpose of this case management visit was address these areas of noncompliance observed during today's visit.

During today's visit, LPA made observations, obtained documents, and conducted interviews with Licensee and I1. LPA was informed that facility currently has one resident in care. However, LPA observed an additional non-personnel Individual 1 (I1) sitting in the facility's common area who appeared to be receiving care. LPA asked Administrator/Licensee if I1 is a resident and Licensee stated they are not. Licensee stated that I1 only came for the day while their primary caregiver went to an appointment. Later, LPA asked I1 how often they come to the facility. I1 stated they come about once per week. LPA asked if I1 ever stays the night and they stated "no." LPA asked I1 if they take medication at the facility, and I1 stated "yes." Licensee was unable to provide LPA with any records for I1. (See LIC809D.)

During Compliant Investigation, LPA was made aware of two staff who work at the facility in addition to the Licensee. During this visit, LPA reviewed the facility personnel report, Guardian roster, and personnel files. Staff 1 (S1) did not have proof of the required annual training hours or annual medication training hours, (see LIC809D). Staff 2 (S2) was not associated to the facility, (see LIC8009D). Additionally, Licensee was unable to provide LPA with multiple required personnel documents including training for S2, (see LIC809D).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 and/or the Health and Safety Code. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given.

Exit interview was conducted with Licensee, whose signature on form confirms receipt of documents.
Bethany MoellersTELEPHONE: (707) 588-5040
Julie FlorioTELEPHONE: (707) 588-5026
DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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Document Has Been Signed on 02/19/2025 04:38 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
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: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
HSC
1569.5

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§1569.5 Regulations authorizing temporary respite care for frail elderly persons...(a)...may require screening of persons to determine the level of care required, a physical history completed by the person’s personal physician....
This requirement is not met as evidenced by:
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Licensee to provide CCLD a complete care record for I1 by POC due date 03/19/2025.
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I1 observed in facility receiving respite care without any documentation, including but not limited to: a contract, centrally stored medication destruction log, physician's medical assessment, proof of negative TB results, a care plan, consent for emergency medical treatment, etc.
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Licensee to submit self certification to CCLD that a complete personnel record is available for review by Licensing personnel upon request by POC due date 03/19/2025.
Type B
03/19/2025
Section Cited
CCR87412(a)

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87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement is not met as evidenced by:
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Licensee was unable to provide LPA proof of required personnel documentation for S2.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany MoellersTELEPHONE: (707) 588-5040
Julie FlorioTELEPHONE: (707) 588-5026

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025

LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/19/2025 04:38 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
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: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
87411(c)

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87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
This requirement is not met as evidenced by:
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Licensee to submit proof of completed annual training and medication training to CCL by POC due date 03/19/2025.
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Licensee was unable to provide LPA proof of completed annual training and medication training hours for both S1 and S2.
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Type B
03/12/2025
Section Cited
CCR87411(g)

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87411Personnel Requirements - General (g) Prior to ... initial presence in the facility, all employees...shall:...Request a transfer of a criminal record clearance as specified in Section 87355(c).
This requirement is not met as evidenced by:
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Licensee to submit proof that S2 has been associated to the facility to CCL by POC due date 03/19/2025.
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S2 was not associated to the facility on the Guardian roster.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany MoellersTELEPHONE: (707) 588-5040
Julie FlorioTELEPHONE: (707) 588-5026

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025

LIC809 (FAS) - (06/04)
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