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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881135
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:36:02 PM

Document Has Been Signed on 03/27/2023 03:36 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:RISING STAR CARE HOME LLCFACILITY NUMBER:
331881135
ADMINISTRATOR:REED, JAMES E.FACILITY TYPE:
740
ADDRESS:40600 CHANTEMAR WYTELEPHONE:
(951) 506-4002
CITY:TEMECULASTATE: CAZIP CODE:
92591
CAPACITY: 6CENSUS: 5DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, James ReedTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, James Reed who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (5) residents present.

The facility is a one story home with (3) bedrooms and (2) bathrooms. The clients served are eldery age 60 and up, with a hospice waiver for (6). LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms. LPA observed gloves and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. LPA observed a 30 day supply of PPE at the facility.



Physical Plant: LPA observed the resident bedrooms. Physical plant, floors, windows, and doors were observed to be clean and in good repair. Fixtures and furniture were in good repair and were present. The outdoor area was observed to be free of hazards. Laundry room was observed to be locked and was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents.

During the walk through LPA spoke with the staff and administrator who stated they use master restroom as a guest restroom for visits and caregivers. LPA observed (2) residents currently reside in the bedroom. LPA observed curtains that were placed in the restroom. The facility will receive a type A violation for this. Plan of correction was documented for this.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff are present for the supervision of residents. Emergency exiting plans, telephone numbers and personal rights were found posted in the facility. The listed administrator, possesses a current administrator's certificate.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: RISING STAR CARE HOME LLC
FACILITY NUMBER: 331881135
VISIT DATE: 03/27/2023
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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and reviewed the facility's staff schedule. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All resident medication was locked in a medication cabinet and locked garage refrigerator.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA observed all facility exits were clear from obstructions. LPA observed emergency food supply in the facility garage along with emergency flashlights.

An exit interview was conducted where a copy of this report along with LIC 809-D page, and appeal rights were provided to Administrator, James Reed.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2023 03:36 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/27/2023 at 01:59 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: RISING STAR CARE HOME LLC
FACILITY NUMBER: 331881135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2023
Section Cited

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(a) Living accommodation...The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility...This requirment was not met as evidenced by:
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Based on obersation and interview, it was found that R1's private bathroom is being used as the guest and caregiver restroom. LPA observed sheer curatins where the residents restroom was located. This poses an immediate personal rights, health or saftey risk to the resident in care.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
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