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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607901
Report Date: 03/26/2026
Date Signed: 03/26/2026 02:00:03 PM

Document Has Been Signed on 03/26/2026 02:00 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
CCLD Regional Office, 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: 5DATE:
03/26/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:58 AM
MET WITH:Ana Duenas, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza conducted an unannounced case management visit. LPA met with Licensee/ Administrator Ana Duenas. Office Manager Andrew Escobar arrived shortly after. The purpose of the visit was to follow-up on items addressed during the Noncompliance Conference (NCC) meeting held on September 17, 2025.

During the NCC meeting licensee agreed to:

  1. Hire an additional staff member within 30 days of (9/17/25) that will work as needed for oversight of record documentation, and other facility responsibilities.
Status: On 11/3/2025, Licensee Ana Duenas hired Office Manager Andrew Escobar. Licensee continues
to be the facility Administrator. Ms. Duenas stated she cannot financially hire an Administrator.
  1. Licensee agreed to submit a written plan, update the Plan of Operation and facility sketch addressing live-in staff accommodations. If a permit for an additional dwelling unit (ADU) has been requested submit proof of documentation.
Status: Licensee stated that the 2 live-in staff, of which one was sleeping in the garage and the other in
the living room are now sleeping in former resident room #3. The room was designated as a
live-in staff room. The facility sketch was updated.

* Pending: An updated Plan of Operation that addresses physical plant changes has not been
submitted. A repeat citation and civil penalty was assessed.

Visit observations:
1. (R1) is not currently enrolled in hospice and their bed had full bed rails,

2. A Vitamin B-12 1,000 mcg was observed unlocked in the living room and Allergy Relief Antihistamine 10 mg was observed unlocked in staff room.

Pursuant to Title 22, citations were issued.


Exit interview was conducted and a copy of the report/appeal rights were issued to Ana Duenas.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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)
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Document Has Been Signed on 03/26/2026 02:00 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/26/2026 at 11:38 AM
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: 03/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2026
Section Cited
CCR
87608(a)(5)(B)

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Postural Supports. 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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Staff agreed to remove the full bed rails.

Please submit a copy of the half bed rails physician's order and a picture R1's bed.
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Based on observation, the licensee did not comply with the section cited above in that (R1) is not enrolled in hospice and their bed had full bed rails, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
03/27/2026
Section Cited
CCR87465(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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Administrator shall submit proof that staff were trained in regulation 87465 and medication storage facility procedures.
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Based on observation, a Vitamin B-12 1,000 mcg was observed unlocked in the living room and Allergy Relief Antihistamine 10 mg was observed unlocked in staff room. This poses an immediate 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/26/2026 02:00 PM - It Cannot Be Edited


Created By: Noemi Galarza On 03/26/2026 at 12:46 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: 03/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2026
Section Cited
CCR
87208(a)

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Plan of Operation. The licensee shall have and maintain a current, written definitive plan of operation for the facility....Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met evidenced by:
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Administrator agreed to submit an updated plan of operation that addresses the physical plant changes and live-in staff accommodations in the home.
* A civil penalty is assessed because it is a repeat violation.
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Based on record review and interviews, Licensee has not submitted an updated Plan of Operation that includes and addresses the physical plant changes made i.e., a former resident room (rm #3) is now the live-in staff room. 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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2026


LIC809 (FAS) - (06/04)
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