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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320129
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:46:45 PM

Document Has Been Signed on 12/12/2022 03:46 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
EL SEGUNDO, 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: 5DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:MELANIE TALLADATIME COMPLETED:
01:00 PM
NARRATIVE
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On 12/12/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA Montoya conducted a risk assessment with Licensee/Administrator Glenda Bustos who confirmed the facility is free of Covid-19 infection. LPA met with two caregivers (S1 and S2) and explained the purpose of today’s visit. House Manager Melanie Tallada later joined the 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) may 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 bedrooms, 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 are stacked and located in the kitchen and there is a second refrigerator/freezer in the garage.

LPA and House Manager Melanie Tallada toured the inside and outside grounds of the physical plant. There are no bodies of water 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CASA DE ESTRELLA
FACILITY NUMBER: 198320129
VISIT DATE: 12/12/2022
NARRATIVE
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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.

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 Note was issued, please see LIC9102-AN. LPA reminded the House Manager and the licensee (via phone) that the facility annual fees are not current. LPA provided the House Manager a copy of LIS printout showing the balance due and a PIN number. LPA also advised House Manager Tallada that the administrator's certificate has expired on 6/19/2021. Tallada stated the administrator has already filed the renewal and waiting for the certificate.

Three 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 House Manager Melanie Tallada.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/12/2022 03:46 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 12/12/2022 at 12:05 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESTRELLA
FACILITY NUMBER: 198320129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

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 and interview, the licensee did not comply with the section cited above. LPA Montoya observed the water temperature next to resident bedroom #A is measured 36.2 degree F. and the water temperature in the bathroom next to resident bedroom #B is measured 36.9 degree F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2022
Plan of Correction
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The House Manager will adjust the water temperature to attain a temperature of not less than 105 degree F and not more that 120 degree F. Water temperature will be checked and recorded every 2 hours for 24 hours. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/12/2022 03:46 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 12/12/2022 at 12:05 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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CASA DE ESTRELLA
FACILITY NUMBER: 198320129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed and took photos of the garage door with a broken window. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2022
Plan of Correction
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The House Manager agreed to repair the broken window of the garage door. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed and took photos of an unrolled water hose on the right side of the backyard. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2022
Plan of Correction
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The House Manager will roll up the water house and ensure it does not obstruct any passageways. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022


LIC809 (FAS) - (06/04)
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