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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000126
Report Date: 01/03/2025
Date Signed: 01/03/2025 04:40:58 PM

Document Has Been Signed on 01/03/2025 04:40 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:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Fatima Rivera, administratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry by facility caregiving staff and facility administrator Fatima Rivera after introducing themselves and stating the purpose of the visit.

There are currently four residents in care, two of which are receiving hospice care. LPAs observed residents relaxing in their respective bedrooms and in the facility's common living areas. LPAs accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has four bedrooms, currently privately occupied. There are three bathrooms throughout the facility, two of which are for use by residents. Two additional rooms on the other side of the house are for use by staff members only and inaccessible to residents.

Bedrooms appeared clean and sanitary. Full bed rails are present in two bedrooms. Residents confirmed to be receiving hospice care and plans of care reviewed to include physician orders for the postural supports. LPAs observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathrooms are equipped with grab bars and slip mats. Hot water temperature measured at 107.7F and 109F.

LPAs observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in a secure drawer. Fire extinguishers are charged and mounted, with up-to-date maintenance documented on the attached tags. LPAs tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a locked metal cabinet closet in the dining area. The attached garage is inaccessible to residents and is used for storage and laundry. Cleaning supplies are stored securely in the passageway to the garage.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STAR DUST HOME
FACILITY NUMBER: 306000126
VISIT DATE: 01/03/2025
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CONTINUED FROM FORM LIC809
LPAs and facility staff toured the outside of the facility. LPAs observed an shaded outdoor seating areas with furniture for resident use. The perimeter gate on one side of the property is self-latching.

LPAs reviewed four resident records which included all necessary components. One physician report for a resident diagnosed with dementia is dated by over a year. Consultation provided. LPAs reviewed resident medication records and prescription orders for all four residents, no discrepancies observed. One resident is assessed to be bedridden per their physician report, which was later confirmed in an interview with the resident's hospice nurse. The facility's current fire clearance does not include a provision for any bedridden residents at this time. Citation issued.

LPAs reviewed three staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately.
Based on the observations made during today’s visit, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Consultations provided on attached Advisory Notes form. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/03/2025 04:41 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 01/03/2025 at 04:16 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: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews with facility and hospice staff along with records reviewed, the licensee did not comply with the section cited above as one resident is found to be bedridden during the visit, while the fire clearance does not include any such provision. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee will submit an updated form LIC200 to request the update of their fire clearance with the Fire Marshall.
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:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


LIC809 (FAS) - (06/04)
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