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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000126
Report Date: 04/19/2024
Date Signed: 04/19/2024 03:44:52 PM

Document Has Been Signed on 04/19/2024 03:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:STAR DUST HOMEFACILITY NUMBER:
306000126
ADMINISTRATOR/
DIRECTOR:		RIVERA, FATIMAFACILITY TYPE:
740
ADDRESS:1825 SAMAR DR.TELEPHONE:
(714) 429-1658
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 4DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Fatima RiveraTIME VISIT/
INSPECTION COMPLETED:
04:04 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Administrator (AD) Fatima Rivera.

For today’s visit, LPA observed a total of 4 residents in care and 2 staff members on duty.

LPA observed the Administrator's Certificate for facility AD Fatima Rivera which expires on 10/06/2024.

LPA Ramirez toured the interior and exterior portions of the facility with AD Rivera. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 4 may be on hospice and 0 bedridden. For this visit, there are a total of 4 residents in care. There are a total of 6 bedrooms, of which 4 are private resident bedrooms, and 2 private bedroom for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 4 restrooms of which 2 are for staff and 2 are for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 109.5-110.8 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located by the laundry room.

LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the kitchen hallway. Facility had back-up emergency food and water supply, located in the garage

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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 4
Document Has Been Signed on 04/19/2024 03:44 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 04/19/2024 at 02:39 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STAR DUST HOME
FACILITY NUMBER: 306000126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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Licensee to email updated staff trainings by 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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/19/2024 03:44 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 04/19/2024 at 02:39 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STAR DUST HOME
FACILITY NUMBER: 306000126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2024
Plan of Correction
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Licensee to email dementia in-service trainings to LPA by 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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STAR DUST HOME
FACILITY NUMBER: 306000126
VISIT DATE: 04/19/2024
NARRATIVE
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LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded area with furniture, and the grounds were free of any hazards. There is 1 gate in the backyard, which is self-closing and self-latching. No bodies of water were observed.

LPA reviewed four resident files and two staff files. LPA interviewed residents and staff present.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Rivera.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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