<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607901
Report Date: 09/02/2022
Date Signed: 09/02/2022 01:56:56 PM

Document Has Been Signed on 09/02/2022 01:56 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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:
09/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator Ana DuenasTIME COMPLETED:
02:00 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's (LPA's) Nune Margaryan and Kimberly Ramirez conducted an annual required visit. LPAs met with caregiver, Macaria Santiago who allowed entry into the home. A short time later administrator, Ana Duenas arrived. LPA's explained the reason for the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed client files, and reviewed staff fingerprint clearances. Facility submitted a mitigation plan on 5/28/21 and it's approved. . Facility is approved to retain/accept three (3) hospice residents. There are currently 2 residents on hospice.

The facility is a single story structure located in a residential neighborhood. LPAs toured the facility. LPAs observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways were free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPAs was screened upon entry. All staff were observed to be wearing mask during this visit. Home consists of the following: 4 resident bedrooms, 2 bathrooms, living room, office area, kitchen, laundry area which is located in the garage, backyard with shaded patio area. Front yard is landscaped with grass. All resident bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was 117.8 degrees which is within the required 105 - 120 degrees. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. Sharps, cleaning supplies are locked and inaccessible to residents.


Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/02/2022
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
26
27
28
29
30
31
32
Carbon monoxide detectors were in compliance and operational. Fire extinguishers observed fully charged. LPAs observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPAs reviewed residents records to confirm emergency contact is updated and residents have health screenings on file. Staff records were reviewed to confirm health screenings and fingerprint clearances. LPA reviewed residents medications. Medications are documented properly and given as prescribed.


Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit.

Exit interview was conducted and the copy of the report was provided to the Administrator .

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2