198320129-11-26-2024-11-AS-ZBRN-DBD3XU-20241125173855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320129
Report Date: 11/25/2024
Date Signed: 11/26/2024 08:13:22 AM

Document Has Been Signed on 11/26/2024 08:13 AM - 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	CASA DE ESTRELLA		FACILITY NUMBER:	198320129
ADMINISTRATOR/ DIRECTOR:	BUSTOS, GLENDA		FACILITY TYPE:	740
ADDRESS:	22313 MADISON STREET		TELEPHONE:	(310) 504-0648
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY: 6		CENSUS: 6	DATE:	11/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:32 PM
MET WITH:	Evangeline Agatep, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:45 PM

NARRATIVE

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On 11/25/2024 at 1:30pm, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the annual inspection. LPA met with Evangeline Agatep, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents of which (1) maybe bedridden. Three (3) the residents are diagnosed with dementia, two (2) residents are receiving home health (0) residents are receiving hospice care services. The facility does not handle any of the residents’ money. The last fire drill was conducted on 10/03/2024. The facility fee is $494.50 and is due on 12/05/2024. LPA provided the pin #055870 to the facility to make annual fee payment online.

The home is a single story home consisting of: (5) resident bedrooms, (2) full bathroom, den, living room, kitchen with dining area, laundry room (located in the kitchen) and two (2) outdoor shaded patio area. LPA toured the resident bedrooms which have the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 113.1 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Report continues on LIC 809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CASA DE ESTRELLA	FACILITY NUMBER: 198320129
	VISIT DATE: 11/25/2024

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Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies:
On 11/25/2024 at 1:40 PM while LPA was conducting a tour of the physical plant, LPA observed:

resident beds had bedrails and reviewed records for Resident #1, Resident #2, Resident #3 and Resident #5 files and did not observe a physicians order on file for the half bed rails.
padlock on exterior gate
For Resident #2, on the physicians report it states that the resident is bedridden, when resident is not bedridden.

An exit interview was conducted with Evangeline Agatep, and a copy of Report and Appeal Rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/26/2024 08:13 AM - It Cannot Be Edited

Created By: Zina Brown On 11/25/2024 at 04:53 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CASA DE ESTRELLA	FACILITY NUMBER: 198320129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(5)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, 1 of the resident records review, indicated on the physicians record, the resident is bedridden. Based on LPA observation and other records reviewed, resident does not appear to be bedridden. This poses as a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	The administrator shall clarify residence ambulatory status to determine if the residence are bedridden or non-ambulatory. The facility will submit proof of updated physician report by POC due date via email at zina.brown@dss.ca.gov

Type B

Section Cited

CCR

87705(l)(1)

Care of Persons with Dementia

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above. LPAs observed two exterior front gates had padlocks in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	Licensee will adhere to Title 22 Regulation 87705(l)(1) and remove padlocks from front gate exterior or notify licensing agency for an exemption to maintain gate locks. Proof of correction must be sent to zina.brown@dss.ca.gov within 24 hours of 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:

Janae Hammond

LICENSING EVALUATOR NAME:

Zina Brown

LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 11/26/2024 08:13 AM - It Cannot Be Edited

Created By: Zina Brown On 11/25/2024 at 05:00 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CASA DE ESTRELLA	FACILITY NUMBER: 198320129
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(3)

(a) Based on the indivdual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, records review and observation, Resident #1-#3 and Resident #5 have half bed rails but no physician order on file which poses as a personal rights risk to residents in care.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	The licensee/administrator will obtain physician order and submit a copy to the department by POC date.

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.

SUPERVISOR'S NAME:

Janae Hammond

LICENSING EVALUATOR NAME:

Zina Brown

LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

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