496803499-5-18-2023-21-AS-DALO-CRXRX4-20230518132405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803499
Report Date: 05/18/2023
Date Signed: 05/18/2023 01:24:12 PM

Document Has Been Signed on 05/18/2023 01:24 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:	SILVER STAR		FACILITY NUMBER:	496803499
ADMINISTRATOR:	KUMAR, AMI		FACILITY TYPE:	740
ADDRESS:	1966 DENNIS LANE		TELEPHONE:	(707) 595-3605
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 5	DATE:	05/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Janine Sorenson-Administrator		TIME COMPLETED:	01:20 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) Alviso, arrived unannounced to conduct a Required -1 Year visit, on 5/18/23 at approximately 9:30am, and met with Licensee/Administrator Ami Kumar, and Janine Sorenson, facility Administrator. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. The facility has an infection control plan, and submitted required plan to the Department. LPA discussed with the Licensee and Administrator to review the newest PIN 23-12, and ensure to update infection control plan as/if needed. Submit a copy when the plan has been updated. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden. The LPA toured the facility with the Licensee and the Administrator. The hot water was checked at 110.F which is within regulation Fire extinguishers(3 of 3) were serviced and tagged as required, expires 2/6/24. All exits were free and clear of obstructions. Facility was found to be clean, orderly, and at a comfortable temperature. Toxins/cleaners are stored in locked cabinets. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. Required postings were up and visible. LPA observed a sufficient supply of perishable and non-perishable food, emergency food & water supplies, hygiene supplies, cleaners, and paper products. LPA observed a sufficient supply of personal protective equipment(PPE). The LPA reviewed four(4) staff files. All staff have required criminal record clearance. All staff have required current First Aid certification, including CPR certification. LPA reviewed required staff training. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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: SILVER STAR	FACILITY NUMBER: 496803499
	VISIT DATE: 05/18/2023

NARRATIVE

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The LPA reviewed five(5) of five(5) resident files. All resident files were complete.

Licensee/Administrator to submit updates of the following documents by 6/18/2023:
LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

During the tour of the facility, the LPA observed a prescription medication bottle in a resident's(R2) room on a tray table, the resident can't handle their own medications, per file review. The medications are required to be crntrally stored, the facility also has dementia residents in care. This deficiency will be cited,87465 Incidental Medical and Dental Care (h)(2) The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. 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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/18/2023 01:24 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: SILVER STAR	FACILITY NUMBER: 496803499
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h)(2) The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, a medication bottle was in a resident's room on a tray table, resident (R2) can't handle own medicatons, the licensee did not comply with the section cited above in [1] out of {5] resident medications, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	icensee/Administrator to ensure all medications are centrally stored as required by regulations and Doctor's Orders of resident(s). Licensee to ensure all staff obtain training in policy and procedures of centrally storing medications in compliance with regulations. Proof of training due 5/25/23. Plan of correction regarding the deficiency cited is due 5/19/23.

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) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC809 (FAS) - (06/04)

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