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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801846
Report Date: 02/26/2026
Date Signed: 02/26/2026 02:56:32 PM

Document Has Been Signed on 02/26/2026 02:56 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: 1DATE:
02/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:18 AM
MET WITH:Estrella Valendo-Administrator TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection and was greeted by Administrator (admin) Estrella Valendo. Facility is an Adult Residential Facility for the Elderly licensed for a capacity of 6 residents. There is currently 1 resident in care.

LPA toured the building and grounds which 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. Expiration dates were not noted in some food items in refrigerator (Technical Violation given). Knives found in kitchen not secure or locked accessible to resident (Deficiency cited, see 809D) Civil Penalty for Repeat Violation Assessed. Resident bathroom had required bath mat and grab bar. Bathroom found with paper towels and toilet paper. Dryer and washer found operational. Toxins found in laundry room was found unlocked (Deficiency Cited, see 809D) Water temperature in sink accessible to residents in care measured within the allowable range of 105 to 120 degrees F. One resident bedroom is in use and observed to be equipped with lighting, night stand, and chest of drawer. LPA toured the outside backyard of facility and observed that outdoor studio apartment was removed and replaced with patio furniture. Noticeable spider webs and collected dust observed throughout facility (Technical Violation given). LPA observed garage had vermin droppings and noticeable odor of decay throughout the garage. In addition, vermin observed in kitchen floor (Deficiency cited, see 809D) Civil Penalty for Repeat Violation Assessed.

At approximately 12:00, LPA conducted file review for one resident. ID Emergency Information missing for resident. LPA printed copy and advised admin to sign and keep in file. LPA conducted file review for 2 staff. Training found to be up to date. LIC503 Health Screening missing for S1, TB cleared (Technical Violation given).

Continued onto 809C.....
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Ethel Contreras
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2026
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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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)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GOLDEN STAR HOME
FACILITY NUMBER: 486801846
VISIT DATE: 02/26/2026
NARRATIVE
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continued from 809C....

Fire extinguishers were last inspected 1/22/2026. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Admin unable to provide disaster drills being conducted quarterly (Deficiency Cited, see 809D).

Resident at home is not currently taking any medications. No medication check was needed. In addition, LPA did not observe any unsecured medication in facility.

Discussion was had with admin for an office meeting scheduled for 3/25/2026.

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

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: 02/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 02/26/2026 02:56 PM - It Cannot Be Edited


Created By: Ethel Contreras On 02/26/2026 at 01:40 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: 02/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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Based on LPA and admin observation, the licensee did not comply with the section cited above in that sharp knives in kitchen unlocked and not secure accessible to resident in care including chemicals in laundry room not locked which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Facility to submit LIC9098 self-certifying the facility will keep all sharp knives in locked cabinets by plan of correction due date 2/27/2026
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: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/26/2026 02:56 PM - It Cannot Be Edited


Created By: Ethel Contreras On 02/26/2026 at 01:40 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: 02/26/2026

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
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Based on LPA and admin observation licensee did not comply with the section cited above in that vermin and/or rodent droppings found throughout garage and kitchen floor of facility which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Licensee to contact a pest control company or exerminator and schedule an appointment to come to facilty to clear vermin/droppings. Facility to provide copy of scheduled visit by plan of correction due date 3/05/2026.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and admin observation and record review, the licensee did not comply with the section cited above facility Unable to provide proof of disaster drills being conducted which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Licensee or Administrator will Self Certify on an LIC 9098 that they will conduct Emergency Disaster Drills quarterly. In addition, Licensee or Administrator will conduct an Emergency Disaster Drill and submit proof of the Emergency Disaster Drill and the LIC 9098 to Community Care Licensing by the POC due date of 3/05/2026.
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: 02/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2026


LIC809 (FAS) - (06/04)
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