Golden Star Home

Type of visit: Office

An Informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Analyst Ethel Contreras , Licensing Program Manager (LPM), Kim Mota, Administrator Estrella Valendo and staff Naomi Subala . The purpose of the Informal meeting was to address compliance issues outlined below: Areas of Concern Discussed: - Facility has Clark pest control but will look into contracting a rat exclusion/exterminator - Facility has changed the storage of the rice to an air tight container - Administrator change in process - TSP offered and agreed for facility During today's meeting we discussed food services, pest control and administrator changes. In addition client concerns and needs were discussed. Exit interview conducted with licensee, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Mar 25, 2026

Type of visit: Required - 1 Year

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..... 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.the state’s words, verbatim · CDSS document, Feb 26, 2026

Allegation investigated: Reporting Requirements

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 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. 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.the state’s words, verbatim · CDSS document, May 13, 2025 · control 21-AS-20250218132605

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 13, 2025

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: 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.the state’s words, verbatim · CDSS document, May 13, 2025

Plan of correction: 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.

Type of visit: Required - 1 Year

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.... 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).... 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.the state’s words, verbatim · CDSS document, Apr 22, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct an initial 10-day Complaint Investigation Visit and subsequently discovered other unrelated deficiencies resulting in this Case Management - Deficiencies Inspection. The purpose of this case management visit was address these areas of noncompliance observed during today's visit. During today's visit, LPA made observations, obtained documents, and conducted interviews with Licensee and I1. LPA was informed that facility currently has one resident in care. However, LPA observed an additional non-personnel Individual 1 (I1) sitting in the facility's common area who appeared to be receiving care. LPA asked Administrator/Licensee if I1 is a resident and Licensee stated they are not. Licensee stated that I1 only came for the day while their primary caregiver went to an appointment. Later, LPA asked I1 how often they come to the facility. I1 stated they come about once per week. LPA asked if I1 ever stays the night and they stated "no." LPA asked I1 if they take medication at the facility, and I1 stated "yes." Licensee was unable to provide LPA with any records for I1. (See LIC809D.) During Compliant Investigation, LPA was made aware of two staff who work at the facility in addition to the Licensee. During this visit, LPA reviewed the facility personnel report, Guardian roster, and personnel files. Staff 1 (S1) did not have proof of the required annual training hours or annual medication training hours, (see LIC809D). Staff 2 (S2) was not associated to the facility, (see LIC8009D). Additionally, Licensee was unable to provide LPA with multiple required personnel documents including training for S2, (see LIC809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 and/or the Health and Safety Code. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Exit interview was conducted with Licensee, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.5 · Plan of correction due date: Mar 19, 2025

§1569.5 Regulations authorizing temporary respite care for frail elderly persons...(a)...may require screening of persons to determine the level of care required, a physical history completed by the person’s personal physician.... This requirement is not met as evidenced by: I1 observed in facility receiving respite care without any documentation, including but not limited to: a contract, centrally stored medication destruction log, physician's medical assessment, proof of negative TB results, a care plan, consent for emergency medical treatment, etc.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Licensee to provide CCLD a complete care record for I1 by POC due date 03/19/2025. Licensee to submit self certification to CCLD that a complete personnel record is available for review by Licensing personnel upon request by POC due date 03/19/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Mar 19, 2025

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: Licensee was unable to provide LPA proof of required personnel documentation for S2.the state’s words, verbatim · CDSS document, Feb 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Mar 19, 2025

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Licensee was unable to provide LPA proof of completed annual training and medication training hours for both S1 and S2.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Licensee to submit proof of completed annual training and medication training to CCL by POC due date 03/19/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(g) · Plan of correction due date: Mar 12, 2025

87411Personnel Requirements - General (g) Prior to ... initial presence in the facility, all employees...shall:...Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by: S2 was not associated to the facility on the Guardian roster.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Licensee to submit proof that S2 has been associated to the facility to CCL by POC due date 03/19/2025.

Type of visit: Required - 1 Year

LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Caregiver Normita Subala. The facility has locked cabinets for medications and cleaning chemicals. Each room has an exit to the outside. There is an ample supply of perishable and nonperishable food. Staff have the required training. The following was observed during today's visit: -The front door has a latch that connects the frame to the front door and has a key to lock the latch. This is not allowed because it is not part of the door knob. This prevents residents from going out the front door. -The front and back door has a latch that is not part of the original lock on the door. The latch is attached to the door frame and is pushed up and the over to cover part of the door and pushed down preventing people from getting out. -the front door audio alert was turned off. This is required when having residents who have wandering behaviors -two of the three resident records have a diagnosis of dementia and their physician's reports are over 12 months old. Per Title 22 regulations someone with a diagnosis of dementia shall have an updated physician's report every 12 months. Today, LPA advised Caregiver that medications shall be prepared each time they are required to be given. Prepouring medication is not allowed The following shall be updated and submitted to Community Care Licensing Division by 04/30/2024: -LIC 400 Affidavit Regarding Client/Case Resources -if the facility is handling resident monies, the facility shall obtain a surety bond and submit a copy to Community Care Licensing Division. If the facility is not handling resident monies a surety bond is not required. -liability insurance -LIC 500 facility personnel or staff schedule -copy of current administrator certificate. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 15, 2024