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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850362
Report Date: 11/07/2024
Date Signed: 11/07/2024 05:00:25 PM

Document Has Been Signed on 11/07/2024 05:00 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:STARS BOARD AND CARE FACILITY INCFACILITY NUMBER:
195850362
ADMINISTRATOR/
DIRECTOR:
ZAKARYAN, NAHAPETFACILITY TYPE:
740
ADDRESS:15511 SATICOY STTELEPHONE:
(818) 616-3007
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 2DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Emma KochinyanTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena conducted an annual required visit to the above noted facility. The LPA was greeted by staff. Staff contacted facility representative Emma Kochinyan, who arrived thereafter.
The LPA and the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA reviewed physical plant findings with facility representative once the representative arrived at the facility.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. There is a fireplace in the living room, it was observed to be screened. There is a functioning telephone on the premises.


The two (2) fire extinguishers were observed to have been purchased on 02/20/2023 and were expired at the time of today’s inspection. The LPA observed that the required postings were missing, except for the Facility License. Missing postings: Ombudsman Poster, Community Care Licensing Poster, Personnel Schedule (LIC 500), Resident Roster (LIC 9020), Residents’ Rights, and Facility Floor Plan/sketch.

KITCHEN: Kitchen knives are stored inaccessible in a drawer to the right of the stove.The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. Appliances in the kitchen were clean and all appeared functional at the time of the visit. Trash cans had tight fitting lids. The first aid supplies were complete, including a thermometer and a current version of a first aid manual.


BEDROOMS: The facility has three (3) shared residents’ bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bedroom #1 had two residents at the time of the inspection. Continues on LIC 809C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 11
Document Has Been Signed on 11/07/2024 05:00 PM - It Cannot Be Edited


Created By: Sandra Urena On 11/07/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARS BOARD AND CARE FACILITY INC

FACILITY NUMBER: 195850362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of two staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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2
3
4
Licensee agreed to have staff files completed by above date, and send email to LPA.
Type A
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of two staff do not have training as required, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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2
3
4
Licensee agreed to proide the required training for staff, beginning with the medication training, and complate all 40 hours of training as specified in the regulation. Licensee will submit all proof of training to LPA via email.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 11/07/2024 05:00 PM - It Cannot Be Edited


Created By: Sandra Urena On 11/07/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARS BOARD AND CARE FACILITY INC

FACILITY NUMBER: 195850362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of two staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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2
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4
Licensee agreed to proide the required training for staff, beginning with the medication training, and complate all 40 hours of training as specified in the regulation. Licensee will submit all proof of training to LPA via email.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 11/07/2024 05:00 PM - It Cannot Be Edited


Created By: Sandra Urena On 11/07/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARS BOARD AND CARE FACILITY INC

FACILITY NUMBER: 195850362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
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Based on record review)], the licensee did not comply with the section cited above in two out of two personnel files were not complete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee agrre to submit of completed Personnel files to LPA via email.
Type B
Section Cited
CCR
87468(d)
Personal Rights of Residents
(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above as the Residents Personal Rights were not posted in facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee agreed to post all required postings by above date and sendpicture of postings to LPA proof via email.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 11/07/2024 05:00 PM - It Cannot Be Edited


Created By: Sandra Urena On 11/07/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARS BOARD AND CARE FACILITY INC

FACILITY NUMBER: 195850362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in one out of two files didnot have an updated medical asessment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee agreed to submit proof of updated Physicians Report via email to LPA.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in one out of two residents files did not have an updated appraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee agreed to submit proof of updated Appraisal via email to LPA.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 11/07/2024 05:00 PM - It Cannot Be Edited


Created By: Sandra Urena On 11/07/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARS BOARD AND CARE FACILITY INC

FACILITY NUMBER: 195850362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review)], the licensee did not comply with the section cited above in one out of two residents physician report did not have an updated TB test, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee agreed to submit proof of correction via email to LPA.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above as in one out of two pre-appraisal were not updated prior to admission, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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2
3
4
Licensee agreed to submit proof of correction via email to LPA.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 11/07/2024 05:00 PM - It Cannot Be Edited


Created By: Sandra Urena On 11/07/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARS BOARD AND CARE FACILITY INC

FACILITY NUMBER: 195850362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87508(a)
Register of Residents
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) and (record review)], the licensee did not comply with the section cited above in two out of two did not have a residents register, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
1
2
3
4
Licensee agreed to submit proof of correction via email to LPA by above date.
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 record review)], the licensee did not comply with the section cited above as three out of four drill have not been conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
1
2
3
4
Licensee agreed to submit proof of correction via email to LPA by above date.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 11/07/2024 05:00 PM - It Cannot Be Edited


Created By: Sandra Urena On 11/07/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARS BOARD AND CARE FACILITY INC

FACILITY NUMBER: 195850362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(f)(3)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in two out of two staff do not have the required training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
1
2
3
4
Licensee agreed to submit proof of correction via email to LPA by above date, or as soon as training has been completed.
Type B
Section Cited
CCR
87611(c)
General Requirements for Allowable Health Conditions
(c) In addition to Section 87411(d), facility staff shall have knowledge and the ability to recognize and respond to problems and shall contact the physician, appropriately skilled professional, and/or vendor as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in two out of two staff do not have the required training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
1
2
3
4
Licensee agreed to submit proof of correction via email to LPA by above date, or as soon as training have been completed.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 11/07/2024 05:00 PM - It Cannot Be Edited


Created By: Sandra Urena On 11/07/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARS BOARD AND CARE FACILITY INC

FACILITY NUMBER: 195850362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)(6)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in two out of two staff do not have the required trainig, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
1
2
3
4
Licensee agreed to submit proof of correction via email to LPA by above date, or as soon as training has been completed.
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in two out of two staff do not have the required training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
1
2
3
4
Licensee agreed to submit proof of correction via email to LPA by above date, or as soon as training has been completed.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 11/07/2024 05:00 PM - It Cannot Be Edited


Created By: Sandra Urena On 11/07/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARS BOARD AND CARE FACILITY INC

FACILITY NUMBER: 195850362

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(3)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in two out of two staff do not have the required training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
1
2
3
4
Licensee agreed to submit proof of correction via email to LPA by above date, or as soon as training has been completed.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
Page: 10 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: STARS BOARD AND CARE FACILITY INC
FACILITY NUMBER: 195850362
VISIT DATE: 11/07/2024
NARRATIVE
1
2
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BEDROOMS: Residents’ beds were observed to have full bed rails at the time of the inspection. Bedrooms’ number #2 and #3, were empty. Bedroom #2 was being used a staff’s bedroom at the time of the inspection. Facility representative stated that the night staff uses it for sleeping, since they haven’t had more than two residents since facility opened. The pre-licensing visit states that nocturnal (NOC), will be awake night staff only. There is no staff room designated in the facility sketch; consequently bedroom #2 cannot be used for staff use unless the facility licensee decides to make changes to the facility application. Facility representative has agreed to clean out the room. There was a linen closet in the hallway with extra towels and linens.

BATHROOMS: There are two (2) bathrooms total. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. The laundry room is located on the exterior of the house attached to the home. Cleaning supplies and toxins were observed stored and the room will be inaccessible to residents in care. The garage is located detached to the home, and the LPA observed supplies are stored in the garage. No bodies of water were observed.

RECORDS: Records review began at 1:01 p.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. One out of two residents’ files did not have updated required documentation. Personnel records were reviewed for, and were observed to be missing health assessments, criminal record clearances, first aid/CPR training, and the appropriate trainings. File for Administrator was not located at the facility. Two out of two staff files were missing: Health screenings/TB clearances, required 40-hour training, Criminal statement, Personnel Record, etc.MEDICATIONS: Medications review began at 1:50 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and were checked for expiration dates. Medications were properly documented on the centrally stored medications and destruction record; for two out of two residents (Resident #1, Resident #2), the pill count was off during the medication audit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.Citations were issued. Exit interview conducted. A copy of the report was issued and Appeal Rights were issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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