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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801846
Report Date: 04/22/2025
Date Signed: 04/22/2025 04:32:31 PM

Document Has Been Signed on 04/22/2025 04:32 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GOLDEN STAR HOMEFACILITY NUMBER:
486801846
ADMINISTRATOR/
DIRECTOR:		VALENDO, ESTRELLAFACILITY TYPE:
740
ADDRESS:672 RUBIER WAYTELEPHONE:
(707) 374-4087
CITY:RIO VISTASTATE: CAZIP CODE:
94571
CAPACITY: 6CENSUS: 3DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:42 AM
MET WITH:Estrella Valendo TIME VISIT/
INSPECTION COMPLETED:
04:46 PM
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Licensing Program Analysts (LPAs) Coppo and Contreras arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Estrella Valendo.

At approximately 10:30am LPA and Admin toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Frozen chilis found opened and uncovered in freezer expired from October 2024.Frozen mushrooms found with black and brown substance unwrapped. Head of lettuce found in overflow refrigerator with black and brown substance with pooling liquid in wrapping. Bread packages found expired from March 2025.Rice container found with live bugs crawling and noticeable rodent droppings inside rice container (deficiency cited, see 809D).



Sharp knife found in kitchen drawer unlocked. Sharps container found in kitchen counter accessible to residents, LPAs discussed with admin maintaining location of sharps container inaccessible to residents(deficiency cited, see 809D).

All bedrooms were equipped with lighting, night stand, and chest of drawer. Bedrooms have doors leading outside alarms present but not operational. LPAs discussed with admin ensuring doors have operating alarms. Room two (2) had noticeable odor of incontinence . Additionally, facility has a cat and incontinence odor could also be from animal waste(deficiency cited, see 809D).

Resident bathroom had required bath mat and grab bar. Bathroom found without any paper towels to dry hands. Bathtub faucet in disrepair. Toxins found in laundry room was found unlocked. Dryer and washer found operational. Water temperature in sink accessible to residents in care measured at 105.1 degrees F which is within the allowable range of 105 to 120 degrees F.

continued on 809C....
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846
VISIT DATE: 04/22/2025
NARRATIVE
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 continued from 809....

Fire extinguishers were last inspected 2/26/2025. Smoke/Carbon Monoxide detectors located throughout the facility were not operational as the actual detector was removed and not connected to the wires in the ceiling. Administrator stated that detectors will be replaced by construction workers(deficiency cited, see 809D).

Currently facility is under going construction in the backyard; they are building a studio apartment. Backyard is not accessible to residents as many trenches are open, exposing pipes and presenting tripping hazards. Additionally, pavers present but scattered and stacked among mounds of dirt. Administrator stated they do not have a building permit but are in the process of applying for one. LPA's discussed with admin that residents are required to have a safe area in and have access to an outdoor area with shade provided present for activities(deficiency cited, see 809D) Staff bedroom found in garage had vermin droppings and noticeable odor of decay(deficiency cited, see 809D)

At approximately 12:15am LPA conducted a review of 3 resident records. All required documentation present.

At approximately 12:30am LPA conducted review of 2 staff records. S1 is fingerprint cleared but is not associated to the facility. Per admin, S1 is a part time employee. LPA discussed with admin all employees much be associated to the facility whether or not part time. Training for S1 not present or on file. All other required documentation present. LPA's and admin discussed that part time employees must have training completed even if they are just part time (deficiency cited, see 809D).

At approximately 1:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Food thickener found in unlocked cabinet with other perishables. Administrator put away thickener and moved to medication cabinet. Single pill found in pre-poured container on table counter. Another single pill found on kitchen counter accessible to residents.

Continued on 809C(2)....

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846
VISIT DATE: 04/22/2025
NARRATIVE
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continued from 809C....

Refrigerated prescription medications are locked but over the counter medication also stored in refrigerator. However, refrigerator does not have lock. LPAs discussed with admin to get a locking refrigerator or putting a lock on (deficiency cited, see 809D). Newly prescribed medication not on Centrally Stored Medication Log (CSML) for R1. LPA's compared doctors orders to CSML and found some medications prescribed but not on CSML. Facility uses a MAR and medications missing from CSML were found on the MAR. However, LPA discussed with admin use of MAR good policy but all medications must be listed on CSML(deficiency cited, see 809D).

Estrella Valendo Administrator Certificate 7001499740 expires 10/17/23. However, LPA verified admin is currently on Pending List.


LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
Copy of Deed

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with administrator.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 04/22/2025 04:32 PM - It Cannot Be Edited


Created By: Ethel Contreras On 04/22/2025 at 03:02 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review the licensee did not comply with the section cited above in that CSML not completed for all residents requiring medication administration which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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2
3
4
Facility to submit to CCL plan to complete centrally stored medication logs for all residents by plan of correction due date 4/23/2025. Completed as CSML to be submitted to CCL no later than 4/29/25.
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 04/22/2025 04:32 PM - It Cannot Be Edited


Created By: Ethel Contreras On 04/22/2025 at 03:13 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and admin observation and interview, the licensee did not comply with the section cited above in that Monoxide detectors located throughout the facility were not operational as the actual detector was removed and not connected to the wires in the ceiling have batteries which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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2
3
4
Facility to submit pictures of installed and operational smoke alarms and carbon monoxide detectors by plan of correction due date 4/23/25.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on LPA and admin observation, the licensee did not comply with the section cited above in that sharp knife found in kitchen drawer unlocked. Sharps container found in kitchen counter accessible to residents, which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Facility to submit LIC9098 self-certifying the facility will keep all sharp knives and sharps container in locked cabinets by plan of correction due date 4/23/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 04/22/2025 04:32 PM - It Cannot Be Edited


Created By: Ethel Contreras On 04/22/2025 at 03:13 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and admin observation and record review the licensee did not comply with the section cited above in that medications found accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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2
3
4
Facility to submit LIC9098, self certifying all medications will remain inaccesible to residents by POC 4/23/25
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 04/22/2025 04:32 PM - It Cannot Be Edited


Created By: Ethel Contreras On 04/22/2025 at 03:13 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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
1
2
3
4
Based on LPA and admin observation the licensee did not comply with the section cited above in that Rodent droppings found in storage room and staff room in garage and bathtub faucet/spiket is broken and hanging down, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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2
3
4
Facility to provide pictures of storage room clear of all rodent droppings and picture of repaired bathtub faucet by plan of correction due date 5/13/25
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 04/22/2025 04:32 PM - It Cannot Be Edited


Created By: Ethel Contreras On 04/22/2025 at 03:13 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and admin observation and record review, the licensee did not comply with the section cited above in that S1 is a part time employee. Training for S1 not present or on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2025
Plan of Correction
1
2
3
4
Facility to submit completed training records and the number of hours required by regulation by POC due date 4/29/25

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 04/22/2025 04:32 PM - It Cannot Be Edited


Created By: Ethel Contreras On 04/22/2025 at 03:13 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(i)
Planned Activities
(i) The licensee shall implement reasonable interventions in order to ensure the safety of all residents utilizing indoor and outdoor areas and take precautions to prevent residents from unsafe wandering and elopement, as defined in Section 87101, Definitions. Such precautions may not conflict with residents' personal rights as specified in Section 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and admin observation and interview the licensee did not comply with the section cited above in that Backyard is not accessible to residents as many trenches are open, exposing pipes and presenting tripping hazards. Additionally, pavers present but scattered and stacked among mounds of dirt which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
1
2
3
4
Facility to submit pictures that ensure backyard is suitable and safe. Additionally, facility to submit copy o building permit from city of Rio Vista for backyard construction of apartment studio. By no later than 5/6/25
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and admin observation the licensee did not comply with the section cited above in that Frozen chilis found opened and uncovered in freezer expired from October 2024. Frozen mushrooms found with black and brown substance unwrapped. Head of lettuce found in overflow refrigerator with black and brown substance with pooling liquid in wrapping. Bread packages found expired from March 2025. Rice found with bugs and rodent droppings which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2025
Plan of Correction
1
2
3
4
Admin immedietly discared all spoiled food items, expired items and rice. Deficency cleared
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 04/22/2025 04:32 PM - It Cannot Be Edited


Created By: Ethel Contreras On 04/22/2025 at 03:13 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and admin observation the licensee did not comply with the section cited above in that R2 bedroom, room #2 has noticable dor of incontinence which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 04/29/2025
Plan of Correction
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Facility to submit LIC9098 seld certifing facility will remain free of incontinence odors by plan of correction due date 4/29/25
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Ethel Contreras
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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