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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607901
Report Date: 09/06/2025
Date Signed: 09/06/2025 05:19:20 PM

Document Has Been Signed on 09/06/2025 05:19 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:STARLIGHT CARE HOMEFACILITY NUMBER:
197607901
ADMINISTRATOR/
DIRECTOR:		ANA F. DUENASFACILITY TYPE:
740
ADDRESS:1704 KERRY COURTTELEPHONE:
(626) 824-6343
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 6DATE:
09/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:44 AM
MET WITH:Caregiver Antonio Santiago TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 9/06/2025 and was greeted by Caregiver Antonio Santiago. Administrator Ana Duenas arrived shortly after. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to resident#1 (R1). Per R1's physician report, R1 may not have access to these items. Staff immediately removed these items upon LPA's observation. LPA Ramirez observed ZZZQuil supplement and Ultra Strength Sleep aid supplements on top of R1's nightstand. Per R1's physician report, R1 may not have access to these items. Staff immediately removed these items upon LPA's observation. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed non-slip coating in showers. LPA Ramirez observed seated shower chairs in bathrooms. LPA Ramirez observed 2 discarded hospital bed frames blocking passageway access to from bedroom#3. Staff are throwing disposing R1, R3 and R4's used lancets in the trash can. LPA Ramirez observed bathroom cabinet drawer in bedroom#3 to be in disrepair and exposing sharp screws.

See 809-C for continued narrative

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2025
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 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
VISIT DATE: 09/06/2025
NARRATIVE
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Food Service: LPA Ramirez observed a sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C).

Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: personal rights, and nondiscrimination notice. LPA Ramirez observed Complaint Poster (PUB 475) was not 20”x26” as required. LPA Ramirez observed facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Proof of quarterly Emergency drills was not provided upon request. LPA Ramirez observed an emergency food supply located in pantry.


Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands.
Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cabinet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record.
Staffing: Administrator Certificate for Ana Duenas with an expiration date of 07/26/2027. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.
Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez did not observe the required CPR and First Aid training for three (3) out of the three (3) personnel record reviewed. S1 and S2 did not have the required annual training documented in their personnel file. LPA Ramirez did not observe S2’s health screening in their personnel file. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.

Operational Requirements: The fire clearance is approved for six (6) residents over the age of 59 years old, of which five (5) may be non-ambulatory and one (1) bedridden. This facility may retain no more than three (3) hospice residents. There were three (3) residents on hospice during time of inspection.


Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed.
Fourteen (14) violations were observed and cited during this annual inspection. Exit interview was conducted with Caregiver Antonio Santiago. A copy of this report, 809-D and appeals rights was provided via email.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 09/06/2025 05:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/06/2025 at 03:28 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
, 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: 09/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, R1 had access to disinfectant wipes in their room, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
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Staff removed disinfectant wipes, this clears 24HR correction. Licensee will conduct re-training on above regulation and send proof of re-training by 9/12/2025.
Type A
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, R1 had access to supplements in their room, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
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2
3
4
Staff removed supplements, this clears 24HR correction. Licensee will conduct re-training on above regulation and send proof of re-training by 9/12/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 09/06/2025 05:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/06/2025 at 03:28 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
, 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: 09/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, 3 out of the 3 staff employed do not have proof of CPR and first aid training in their files, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2025
Plan of Correction
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Licensee will draft plan on how the staff will complete CPR/First aid training. Plan must be received via email by 9/7/25. All staff will submit proof of CPR/First Aid by 9/12/25.
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 09/06/2025 05:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/06/2025 at 03:28 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
, 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: 09/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, licensee could not provided liability insurance upon request, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
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Licensee will submit proof of liability insurance by 9/12/25 via email to LPA Ramirez.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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 is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA Ramirez observed bathroom cabinet drawer in bedroom#3 to be in disrepair and exposing sharp screws. the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
1
2
3
4
Licensee will repair or replace bathroom cabinet drawer in resident bedroom#3. LPA Ramirez will return to clear violation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 09/06/2025 05:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/06/2025 at 03:28 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
, 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: 09/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, staff are disgarding used lancets in garbage can, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
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Licensee will draft plan on how staff will dispose of needles and sharps according to above regulation. LPA Ramirez must receive plan via email by 9/12/25.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA Ramirez observed 2 disgarded hospital bed frames blocking passageway access to from bedroom#3, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
1
2
3
4
Licensee will remove disgarded bedframes from passageway. LPA Ramirez will return to clear violation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 09/06/2025 05:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/06/2025 at 03:28 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
, 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: 09/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, licensee's poster is not 20"x26", the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
1
2
3
4
Licnesee will post poster that contains same content as PUB 475 and is 20"x26" and post in main entryway of facility. LPA Ramirez will return to clear violation.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2025


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 09/06/2025 05:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/06/2025 at 03:28 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
, 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: 09/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, R3, R4 and R5 did not have medical assessments in their file, the licensee did not comply with the section cited above in 3 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
1
2
3
4
Licensee will send copies of R3,R4 and R5's medical assessments by 9/12/25. Medical assessments must be emailed to LPA Ramirez by 9/12/25.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, R3 and R6 did not have appraisals in their files, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
1
2
3
4
Licensee will submit R3 and R4 appraisal via email by 9/12/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2025


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 09/06/2025 05:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/06/2025 at 03:28 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
, 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: 09/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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, no fire drills are documented, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
1
2
3
4
Licensee will conduct and document emergency drill by 9/12/25. Proof must be emailed to LPA Ramirez by 9/12/25.
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/06/2025 05:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/06/2025 at 03:30 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
, 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: 09/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.2(a)(1)
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
This requirement is not met as evidenced by:
Staff#1 (S1) was observed sharing resident bedroom#3 with resident# (R4). LPA Ramirez observed S1's bed and personal items on their bed. Staff interviews confirmed this observation.
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/07/2025
Plan of Correction
1
2
3
4
S1's bed and personal belongings must be removed from Resident bedroom#3. LPA Ramirez will return to clear violation.
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/06/2025 05:19 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 09/06/2025 at 04:39 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
, 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: 09/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
(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:
S2 did not have documentation of health screening
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
1
2
3
4
Licensee will email S2's health screening to LPA Ramirez.
Type B
Section Cited
CCR
874119(c)
87411 Personnel Requirements – General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
This requirement is not met as evidenced by:
S1 and S2 did not have proof of annual training.
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2025
Plan of Correction
1
2
3
4
Licensee will draft plan on how staff will comply with above regulation by 9/12/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Ramirez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2025


LIC809 (FAS) - (06/04)
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