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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801846
Report Date: 05/13/2025
Date Signed: 05/13/2025 12:39:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250218132605
FACILITY NAME:GOLDEN STAR HOMEFACILITY NUMBER:
486801846
ADMINISTRATOR:VALENDO, ESTRELLAFACILITY TYPE:
740
ADDRESS:672 RUBIER WAYTELEPHONE:
(707) 374-4087
CITY:RIO VISTASTATE: ZIP CODE:
94571
CAPACITY:6CENSUS: 3DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Estrella Valendo, LicenseeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Reporting Requirements
INVESTIGATION FINDINGS:
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On 05/13/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250218132605 investigation findings regarding the above allegation and met with Estrella Valendo, Licensee. Reporting Party (RP) alleges that the facility did not comply with reporting requirements when Resident 1 (R1) fell on two separate occasions.

LPA Florio conducted 10-day complaint investigation visit on 02/19/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through an interview with the Licensee and obtained “Resident Daily Narrative” charting notes that R1 fell on two occasions but sustained no injuries, did not require assessment by a medical professional, Hospice was notified, and Licensee states R1’s family was notified. An interview with the RP revealed conflicting information.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20250218132605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/13/2025
NARRATIVE
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Continued from LIC9099...

However, during the course of record review, LPA obtained “Narrative Charting” notes from R1’s record which state that R1 was sent to the hospital via 911 on September 26, 2023, for a seizure and on September 27, 2023, for having blood in their stool. The Department was not notified in either of these instances, nor were incident reports submitted as required per regulation, (see LIC9099D).

Based on interviews conducted and records obtained, the allegation that the facility did not follow reporting requirements is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250218132605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87211(a)(1)
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Reporting Requirements 87211(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. [....] This requirement is not met as evidenced by:
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Licensee to submit proof that they have reviewed Title 22 reporting requirements, incidents reports, and how to complete them with all staff to CCL by POC due date 06/13/2025.
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LPA obtained “Narrative Charting” notes for R1 which state that R1 was sent to the hospital via 911 twice in September 2023, the resident was admitted, and facility did not submit incident reports, which poses a potential health, safety, and/or personal rights violation to residents 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250218132605

FACILITY NAME:GOLDEN STAR HOMEFACILITY NUMBER:
486801846
ADMINISTRATOR:VALENDO, ESTRELLAFACILITY TYPE:
740
ADDRESS:672 RUBIER WAYTELEPHONE:
(707) 374-4087
CITY:RIO VISTASTATE: ZIP CODE:
94571
CAPACITY:6CENSUS: 3DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Estrella Valendo, LicenseeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff not following physician's orders
INVESTIGATION FINDINGS:
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On 05/13/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250218132605 investigation findings regarding the above allegation and met with Estrella Valendo, Licensee. Reporting Party (RP) alleges that facility staff did not follow physician’s orders by ensuring that Resident 1 (R1) received prescribed medications as directed.

LPA Florio conducted 10-day complaint investigation visit on 02/19/2025 and obtained documents, made observations, and conducted interviews. Based on medication administration records and centrally stored medication destruction records obtained and interviews conducted with the Licensee and an outside care agency nurse, which all confirmed that physician’s orders were followed and R1’s medications were administered as directed, LPA received conflicting information regarding the above allegation.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250218132605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/13/2025
NARRATIVE
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Continued from LIC9099A...

Based on record review, interviews conducted, and observations made, the allegation that the facility staff did not follow physician’s orders is UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited.

Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5