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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320129
Report Date: 12/03/2021
Date Signed: 12/03/2021 05:44:20 PM

Document Has Been Signed on 12/03/2021 05:44 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CASA DE ESTRELLAFACILITY NUMBER:
198320129
ADMINISTRATOR:BUSTOS, GLENDAFACILITY TYPE:
740
ADDRESS:22313 MADISON STREETTELEPHONE:
(310) 504-0648
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 6DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Henry Cadenas - caregiverTIME COMPLETED:
01:45 PM
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On 12/03/2021, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with caregiver Henry Cadenas and was later joined by Administrator Glenda Bustos and explained the purpose of today’s visit. The facility is licensed to operate for six (6) elderly residents ages 60 and above. The facility is approved for six (6) non ambulatory of which one (1) can be bedridden and two (2) can be under hospice care.

The facility is a single-story structure located in a residential neighborhood. The facility consists of the following: five (5) resident's rooms, three (3) bathrooms of which one (1) is designated for staff only, a living room area, a dining area, kitchen, receiving or visitation room and an attached garage used for storage only. The washer and dryer is stacked and located in the kitchen and there is a second refrigerator/freezer in the garage.

LPA and caregiver Henry Cadenas toured the physical plant. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature was maintained in the facility.


Evaluation Report Continues on LIC 809-C.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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Document Has Been Signed on 12/03/2021 05:44 PM - It Cannot Be Edited


Created By: Don Senaha On 12/03/2021 at 11:52 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESTRELLA
FACILITY NUMBER: 198320129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water in bedroom D bathroom measured 136.8 F at 10:39am and 140.9 F in the kitchen at 10:42am which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2021
Plan of Correction
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Staff immediately lowered the water temperature and the water meausred 108.8 F in the bedroom D bathroom and 111.2 in the kitchen sink.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unlocked drawer in kitchen with knives and scissors accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2021
Plan of Correction
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Staff immediately locked the drawer with the knives and scissors with a key.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021


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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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CASA DE ESTRELLA
FACILITY NUMBER: 198320129
VISIT DATE: 12/03/2021
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, and toxins were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are two (2) fire extinguishers fully charged in the kitchen and the garage. First aid kit was located in the kitchen. Smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed six (6) residents and two (2) staff present during the tour. All mandated inspection control posters were posted.

Advisory Notes – Three (3) Technical Assistance were issued, please see LIC9102-AN.

Two deficiencies were cited during this inspection visit. See 9099-D page.

An exit interview was conducted and a copy of this report was provided to Administrator Glenda Bustos.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC809 (FAS) - (06/04)
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