496803499-9-25-2023-21-AS-VBEI-CYN3M5-20231218172146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803499
Report Date: 09/25/2023
Date Signed: 09/25/2023 01:34:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230915150346

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:	09/25/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Ami Kumar-Administrator		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff prevented resident from having visitors
Facility staff did not adequately dress resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Dina Alviso conducted a complaint inspection, on 9/25/23 at approximately 9:25am, and met with Janine Sorrenson, Administrator. Ami Kumar, Licensee/Administrator arrived to the facility shortly after the LPA.

LPA reviewed resident records, and obtsined copies. LPA conducted interviews with staff, and other interested parties.The investigation revealed that resident R1 was admitted to hospice care on 8/1/23. LPA observed a facility care plan, and a hospice care plan. LPA reviewed medical documentation, including medication orders/records. Per interviews and socumentation reviews,hospice agency was reviewing R1's medications as needed, and instructed facility staff on Physician medication orders. Hospice was visiting the resident once a week in the beginning of services but as resident was transitioning/declining hospice staff was visiting R1 daily.

Continued on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230915150346

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/25/2023

NARRATIVE

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Per interviews with staff, and review of records, facility does have visiting hours, which are adjusted as needed for residents on hospice care. R1 was admitted into care, and responsible party asked that there be no visitors right away so the resident could get settled in. Per staff interviews, R1 had visitor(s)/visitation come in to see them; Staff deny that they didn't allow any visitors to R1. Per interviews and record reviews, staff had a resident care plan in place, and all staff were trained in resident's care needs. Staff stated the resident was well cared for, and appropriately dressed as needed. Facility staff stated they cared for the resident's needs till they passed. Hospice agency care plan was in place, and staff were working with hospice agency ensuring resident's needs were being met. There is differing information from parties interviewed, records reviewed, and information provided by reporting party to the Department. The investigation didn't obtain any information and/or documentation that supported violations having occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations, "staff prevented resident from having visitors and facility staff did not adequately dress the resident" are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC9099 (FAS) - (06/04)

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