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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607901
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:33:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220401123352
FACILITY NAME:STARLIGHT CARE HOMEFACILITY NUMBER:
197607901
ADMINISTRATOR:ANA F. DUENASFACILITY TYPE:
740
ADDRESS:1704 KERRY COURTTELEPHONE:
(626) 810-4104
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY:6CENSUS: 5DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ana Duenas, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility has an insect infestation.
Foods are not properly stored.
Facility is storing expired food.
Facility is hazardous.
Facility lawn is not maintained.
Medication cabinet is not locked.
Facility is utilizing full length bed rails for resident's that are not on hospice.
Facility is not storing an adequate amount of food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed with staff Macaria Santiago. Administrator Ana Duenas arrived shortly after.

The investigation consisted of: LPA toured the interior and exterior physical plant. Staff (S1-S3). No residents were interviewed due to cognitive impairment. Resident roster, resident Face Sheets, and LIC 500 Personnel Report, and extermination/pest control service contract were requested, but not obtained. Administrator stated she will email the documents tomorrow.

Allegation: Facility has an insect infestation. The findings indicate that on 3/30/2022 a visitor observed at least 20 cockroaches and several hundred cockroach eggs in kitchen cabinets, food storage area, utensils, and cabinet storage areas. Community Care Licensing obtained photograph evidence of the infestation of pests. The picture images depict cockroaches, eggs, and dirt/feces surrounding good and kitchenware.
***See LIC 9099C for continuation of report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 28-AS-20220401123352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
VISIT DATE: 04/07/2022
NARRATIVE
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continuation of allegation: "Facility has an insect infestation." Administrator and staff interviews revealed that the cockroach infestation problem has been going on for months. Ms. Duenas stated that they were not able to contract pest control services due to COVID-19 pandemic. However, pest control service companies continued to provide services to facilities; except for incidence of active COVID-19 cases in the facility. Resident interviews were attempted, but due to cognitive impairment the residents were unable to be interviewed. All staff acknowledged the cockroach infestation. During today’s visit, LPA observed live cockroaches, and dead cockroaches throughout the facility in the pest baits.

Allegation: “Foods are not properly stored.” The findings indicate that dry goods were observed to be stored in cockroach infested kitchen cabinets/storage areas. Holes in food packaging and evidence of cockroach consumption was observed. When staff was questioned by visitor about the observation the staff responded, “we do not use these cabinets.” Administrator stated the facility has different style of storing food. Staff interviews confirmed food packaging has been observed to be contaminated by cockroach infestation. LPA observed food storage in the garage, where there were cockroaches on the floor.

Allegation: “Facility is storing expired food.” Based on interviews conducted the findings indicate that on 3/30/22, the facility had expired canned goods on the shelves. Administrator and staff confirmed that the facility had expired canned goods and stated that they may have been misplaced, but that residents are not given expired food. LPA observed canned goods in the kitchen counters and garage. The expired food cans have not been discarded yet.

Allegation: “Facility is hazardous.” Based on observation and picture evidence the findings indicate that the wood ramp to enter the facility is warped and poses a tripping/fall hazard. Staff have placed a rug on top of the warped wood to prevent a tripping hazard. All staff acknowledged the disrepair of the ramp poses a tripping hazard. LPA observed and confirmed the ramp is a hazard to residents in care, staff, and visitors. Discarded bed springs and wheelchair was observed in the backyard. In addition, the facility floors were observed unswept, dirty, and not recently mopped; which poses potential health,

See LIC 9099C for report continuation.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20220401123352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
VISIT DATE: 04/07/2022
NARRATIVE
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Allegation: “Facility lawn is not maintained.” Based observation and picture proof evidence the findings indicate the front and backyard lawns are not maintained and may be a vector to additional infestation. The grass/weeds are overgrown. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Staff acknowledged the lawns were not maintained because the gardener did not show up. Administrator stated the gardener visits twice a month.

Allegation: “Medication cabinet is not locked.” On 3/30/2022 a visitor observed that the medication cabinet was not locked. Staff were asked multiple times to lock the medication cabinet, but staff refused, was not able to demonstrate the lock worked, or that they had a key to the medication storage. Administrator stated that it was unlocked because noon medications were going to be given out. Staff interviews confirmed the medication cabinet was unlocked on 3/30/22. During today's visit the cabinet was observed locked. LPA reviewed and provided a copy of regulation “Care of Persons with Dementia”. Due to cognitive impairment residents were not interviewed.

Allegation: “Facility is utilizing full length bed rails for resident's that are not on hospice.” Based on interviews conducted the findings indicate that on 3/30/22, all resident beds had full-length bedrails that were not securely attached to the bed. Administrator stated there are currently no residents receiving hospice services. Therefore, under no circumstances shall bed rails that extend the entire length of the bed be used, except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. During today’s visit, LPA observed all beds had bedrails. One bed had a full length bedrail, and two beds had two half rails installed making it into a full rail. No physician orders are in place.

Allegation: “Facility is not storing an adequate amount of food.” On 3/30/2022, a visitor did not observe two days’ worth of meals in fresh food. Per Title 22, supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. Staff stated that on 3/30/2022 they did not have much fresh food. LPA observed 2-day supply of food today. However, the two refrigerators were dirty.

Based on observation, picture proof, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6. See LIC 9099D.



Exit interview was conducted with Administrator Ana Duenas. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 28-AS-20220401123352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2022
Section Cited
CCR
87555(b)(27)
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General Food Service Requirements. The following food service requirements shall apply: All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement was not met evidenced by:
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Licensee shall submit a copy of exterminator/pest control service contract, and a written plan addressing the cockroach infestation, pest prevention, and if needed possible relocation of residents.

Submit by POC due date.

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Based on observation and picture proof evidence at least 20 cockroaches and several hundred cockroach eggs were observed in kitchen cabinets, food storage area, utensils, and cabinet storage areas. This poses an immediate health, safety or personal rights risk to persons in care.
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Type B
04/14/2022
Section Cited
CCR
87555(b)(28)
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General Food Service Requirements. The following food service requirements shall apply: All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement was not met evidenced by:
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Licensee shall immediately discard all contaminated food in kitchen cabinets and storage areas.

Submit picture proof and grocery shopping receipts by POC due date.
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Based on observation and picture proof evidence on 3/30/22 a visitor observed dry goods packaging had holes and evidence of cockroach consumption. This poses a potential health, safety or personal rights risk to persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20220401123352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2022
Section Cited
CCR
87555(a)
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General Food Service Requirements. The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents..... All food shall be selected, stored, prepared and served in a safe and healthful manner.
This requirement was not met evidenced by:
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Licensee shall conduct an inventory of all canned goods and discard all expired canned food.

Submit a written plan stating what was done, and proof of staff training by POC due date.
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Based on observation, on 3/30/22 the facility had expired canned good on shelves. Staff interviews confirmed the allegation. This poses a potential health, safety or personal rights risk to persons in care.
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Type B
04/14/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met evidenced by:
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Licensee shall:
1. Install a new ramp.
2. Submit a copy of the ramp installation work order and a picture.
3. Clean and maintain the front and backyard lawn. Submit picture proof of correction.
4. Clean dirty floors and refrigerator.
Submit by POC due date.
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Based on photo evidence the wood ramp at facility entrance is warped and poses a tripping/fall hazard to residents in care, staff, and visitors. The front and backyard lawns had overgrown grass, floors and refrigerator were dirty. This poses a potential health, safety or personal rights risk to persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20220401123352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2022
Section Cited
CCR
87465(h)(2)
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Incidental Medical and Dental Care. 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 was not met evidenced by:
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Licensee shall ensure the medication cabinet is always locked, and that all staff follow 87465 regulations.

Staff training shall be conducted. Submit proof of staff training.
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On 3/30/22 a visitor observed the medication cabinet was not locked. Staff were not able to lock it during the visit. During today's visit, LPA observed the cabinet to be locked. This poses an immediate health, safety or personal rights risk to persons in care.
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Type B
04/14/2022
Section Cited
CCR
87608(a)(5)(B)
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Postural Supports. Postural supports may be used under the following conditions. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement was not met evidenced by:
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Licensee shall remove all full-length bedrails from resident's bed that are not enrolled/receiving hospice services, and remove half rails if there is no physician order.

Submit picture evidence by POC due date.
If applicable submit physician orders.
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On 3/30/22 a visitor observed all resident beds had full-length bedrails that were not securely attached to the bed. However, there are presently no residents receiving hospice services. This poses a potential health, safety or personal rights risk to persons inhealth, safety or personal rights risk to persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20220401123352
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2022
Section Cited
CCR
87555(b)(26)
1
2
3
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5
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General Food Service Requirements. The following food service requirements shall apply: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement was not met evidenced by:
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Licensee shall ensure there is always at least 2-days' worth of fresh perishable food for resident's meals.

Submit a written plan, proof of staff training, and food grocery receipt by POC due date.
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On 3/30/22, a visitor did not observe two days' worth of perishable/fresh food meals. Staff confirmed that they did not have sufficient 2-day supply of food on that day. This poses a potential health, safety or personal rights risk to persons in care.
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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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7