Starlight Facility

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 09:32 AM. LPA met with facility staff who contacted the facility Administrator Nelli Tadevosyan. The Administrator arrived to the facility at 09:53 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:55 AM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: There are four (4) bedrooms in the facility; three (3) are dual occupancy resident rooms and one (1) is a staff room. LPA and facility Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. One (1) resident bed was observed to contain full bed rails. Auditory alarms were observed on facility exits and all were functional at the time of the visit. BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 112.5 and 116.4 degrees Fahrenheit, which is in compliance with regulation. LPA observed both bathrooms to contain appropriately secured under-sink cabinets which contained cleaning supplies and personal grooming supplies. Continued on LIC 809C. COMMON AREAS: This included the living room, hallway, and dining area. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contained a dining table with adequate seating for resident use. The dining area contained a cabinet and drawers with activities for resident use. LPA observed a fire extinguisher mounted in the dining area to be fully charged and purchased on 01/15/2026. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace. LPA observed the hallway closet to contain extra linens. The facility’s combination fire and carbon monoxide alarms were tested at 10:25 AM and were functional at the time of the visit. OUTDOOR SPACE: The facility has one (1) emergency exit gate located on the side of the home. LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain an appropriately fenced off pool that was inaccessible to residents in care. GARAGE: LPA observed the garage to be locked and inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, an extra refrigerator, an extra freezer and the facility’s washer and dryer. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed a secured cabinet which contained resident medications and a complete first aid kit. LPA observed a properly secured under-sink cabinet which contained cleaning supplies. One (1) cabinet was observed to contain adequate emergency food and water supplies. The oven was observed to be equipped with child proofing knobs. Continued on LIC 809C. RECORD REVIEW: Record review began at 10:52 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained all required documents and trainings. Four (4) resident files were reviewed. One (1) resident’s bed was observed to contain full bed rails and the resident was observed to not be enrolled with hospice. LPA informed the Administrator that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Administrator expressed understanding and removed the bed rails at the time of the visit. MEDICATION REVIEW: Medication review began at 12:42 PM. Medications for four (4) of four (4) residents were observed. LPA observed three (3) resident’s Centrally Stored Medication and Destruction record sheets (CSMDR) to have medications quantity and strength improperly documented. LPA observed one (1) resident’s CSMDR to contain inaccurate administration instructions for one (1) medication and for one (1) additional medication to not be logged on the CSMDR. LPA informed the Administrator who immediately corrected the errors on the CSMDRs. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/12/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. Two (2) staff members were interviewed utilizing telephonic translation services. Both staff members interviewed were knowledgeable on the resident’s rights, the different forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 4, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:00 AM. LPA met with facility staff who contacted the facility administrator Nelli Tadevosyan. The Administrator arrived to the facility at 09:17 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:17 AM, the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed a secured cabinet to contain resident medications and a first aid kit. LPA observed a properly secured under-sink cabinet to contain cleaning supplies. One (1) cabinet was observed to contain adequate emergency food and water supplies. The oven was observed to be equipped with child proofing knobs rendering the appliance inoperable while not in use. Continued on LIC 809C. COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. The dining area contained a cabinet and drawers with activities for resident use. LPA observed a fire extinguisher mounted in the dining area to be fully charged and purchased on 01/18/2025. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace. LPA observed a hallway closet to contain extra linens. The facility’s combination fire and carbon monoxide alarms were tested at 10:01 AM and were functional at the time of the visit. BEDROOMS: There are four (4) bedrooms in the facility; three (3) are a dual occupancy resident rooms and one (1) is a staff room. LPA and facility administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. One (1) resident bed was observed to contain full bed rails. Auditory alarms were observed on facility exits and all were functional at the time of the visit. BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 118.9 and 120 degrees Fahrenheit, which is in compliance with regulation. LPA observed both bathrooms to contain appropriately secured under-sink cabinets containing cleaning supplies and personal grooming supplies for resident use. OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located in the backyard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain an appropriately fenced off pool that was inaccessible to residents in care. Continued on LIC 809C. GARAGE: LPA observed the garage to be locked and inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, an extra refrigerator, and an extra freezer. The extra refrigerator was observed to contain resident medications that required refrigeration. RECORD REVIEW: Record review began at 10:02 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. One (1) resident’s admission agreement was observed to be missing signatures. One (1) resident file was observed to be missing a property and valuables sheet, a preadmission appraisal, and a negative Tuberculosis (TB) test. MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for two (2) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/04/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. No staff interviews were able to be conducted at the time of the visit as one (1) staff member had to leave the facility and the Administrator was the only available representative at the time of the visit. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 4, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff mismanaged resident medication

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced initial 10-day complaint visit to investigate the above allegation. Upon arrival at approximately 12:00 pm, the LPA was greeted by caregiver, Ruzanna Melikyan who called the Administrator to inform them of the visit. The Administrator Nelli Tadevosyan was not able to be present during today's visit, however was available at any time during face time. During today's visit the LPA toured the physical plant areas inside and outside and beginning at 12:45 p.m. the LPA conducted a medication audit for two (2) residents, interviewed one residents family member, one (1) resident, and three (3) staff. Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation, "Staff mismanaged resident medication,"; it is the concern of the reporting party that a resident that lived at the facility long ago, received the wrong medication and almost went into cardiac arrest. No dates and/or other information about the alleged incident were provided. The LPA was unable to determine the resident. However, during a medication audit conducted for two (2) out of five (5) residents’ during today’s visit, the LPA observed the following. During Resident 1 (R1’s) medication audit, the LPA observed that R1’s Gabapentin is prescribed to be give one capsule by mouth two times a day, however the medication bottle was documented on the Centrally Stored and Destruction Record (CSDR) as two capsules being given once a day, and the medication bottle only had an evening sticker placed on the cap of the bottle. Upon observation, staff called the Administrator, and the Administrator explained to the LPA that when the resident arrived at the facility, they were getting two capsules once a day at their previous home and continue to do so at the facility. Additionally, R1’s Melatonin and Vit D2 were counted and had one more pill than they should have based on the date started documented on the CSDR. Upon observation, the Administrator stated that they did not know why the count was off, and when discussing R1’s Vit D2 1.25 MG medication that should be given once a week every Friday and should only have two left but have three pills left, they stated that they probably did not give them one last week. Based on the information obtained, although there is not sufficient evidence to support a resident went into cardiac arrest due to being given the wrong medication, medication audit revealed that R1 did not received Gabapentin as prescribed and did not receive their Melatonin and Vit D2 medication on one occasion. Therefore, the allegation of “Staff mismanaged resident medication” is deemed substantiated at this time. Exit interview conducted, deficiency cited, and the report and appeal rights emailed to the licensee.the state’s words, verbatim · CDSS document, Jan 2, 2025 · control 29-AS-20241226105051

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 3, 2025

87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by: Based on interviews and medication audit, the licensee did not comply with the section cited above as R1 did not receive 1 of their medications as prescribed and did not receive 2 of their medications in one occassion,which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 2, 2025

Plan of correction: Licensee agreed to review section cited and provide a statement of understanding as well as a plan to ensure how they ensure that residents will be provided medications as prescribed and send to LPA via email by COB 1/3/2025.

Allegation investigated: Staff yelled at resident while in care. Staff are physically aggressive with residnets. Staff are unable to communicate with residents due to language barrier.

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced initial 10-day complaint visit to investigate the above allegation. Upon arrival at approximately 9:30 am, LPA Mosley was greeted by caregiver, Ruzanna Melikyan who called the Administrator to inform them of the visit. The Administrator Nelli Tadevosyan arrived shortly after and the reason for the visit was explained. On 09/27/2024, the Department received a complaint regarding the following allegations, Staff yelled at resident while in care, Staff are physically aggressive with residents, and Staff are unable to communicate with residents due to language barrier. LPA toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Report Continued on LIC9099C... Unsubstantiated Report continued from LIC9099... On the allegation, Staff yelled at resident and are physically aggressive with residents in care it is the concern of the Reporting Party 1 (RP1) and Reporting Party 2 (RP2) that Staff 1 (S1) is yelling at the residents on a regular basis and and that staff are physically aggressive with residents. To investigate this complaint, LPA conducted telephonic interviews with RP 1, RP 2, and a former resident. In person interviews were conducted with the Administrator, Staff, three (3) out of five (5) residents, two (2) home health CNA Shower nurses, and one (1) family member / visitor at the time of the visit between 10:00 am – 12:30pm. LPA also obtained pertinent documents to the investigation and reviewed facility records. Interviews with three residents currently residing at the facility revealed that the staff treat the residents with dignity and respect. Residents noted that two (2) out of three (3) residents are hard of hearing and require others to be louder when speaking to them. However, there is a difference between yelling and projecting the voice. Residents noted that staff project at times but do not yell at them. In addition, staff are also not physically aggressive with them. Residents stated they are handled with care and stability to ensure their safety, but not aggressively. Interviews with home health CNA shower nurses revealed that staff are attentive and caring. CNA 1 and CNA 2 are at the facility two (2) to three (3) times a week and have not witnessed or heard staff yelling at residents. CNA’s were asked if they have seen any unexplained markings on residents that would be from aggressive behavior such as pulling or pushing. CNA’s both stated they have not witnessed any unexplained marking or anything concerning. Interviews with family member / visitor revealed that they are at the facility three (3) to four (4) times a week, unannounced and have not seen staff yell at residents or any type of aggressive behavior. Family member / visitor stated that the staff have been wonderful and love it at the facility and the quality of care is exceptional. Interview with S1 revealed that residents are not yelled at or mistreated in anyway. S1 stated they have never yelled at a resident, however, must project the voice to be heard by residents who have trouble hearing. Interview with Administrator revealed that no complaints of staff yelling have been made or witnessed. Administrator has no issues with S1s performance. File review was conducted and support that no disciplinary action has been noted on any staff. Report Continued on LIC9099C... Report continued from LIC9099-C... Based on information obtained, there is insufficient evidence to support the allegations occurred. Therefore, the allegations of Staff yelled at resident while in care and Staff are physically aggressive with residents are deemed unsubstantiated at this time. On the allegation, Staff are unable to communicate with residents due to language barrier it is the concern of the RP2 that S1 is unable to communicate with residents due to limited understanding of English. To investigate this complaint, LPA conducted interviews with Residents, S1, and Administrator. Interviews with residents revealed that they can communicate with S1 regarding their basic needs and had no concerns regarding communication. However, if further understanding or a complex conversation is needed, the Administrator is able to translate or the use of a translator application on the phone of S1. Interview with S1 revealed they are able to assist the residents with their needs and that they are knowledgeable in the basic process of emergency procedures and able to assist paramedics in English if needed. Administrator is also readily available and able to translate and assist when and if needed. Administrator noted that S1 is in the process of learning more English. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff are unable to communicate with residents due to language barrier is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 29-AS-20241001091309

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and the LPA informed them of the reason for the visit. Administrator Nelli Tadevosyan arrived shortly thereafter. The LPA and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 72 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. Required postings were observed at the entrance of the facility. There is a television in the living room area. The facility’s smoke/carbon monoxide alarm systems are hard wired. All rooms were tested, and smoke/carbon monoxide alarm systems were in operating condition. KITCHEN: A seven-day supply of non-perishable food, and perishable food supply was available. The supply of dishes is adequate. The appliances in the kitchen were clean and all appeared functional. House cleaning supplies are stored in locked cabinet under the sink. There were no pesticides or toxins stored near food, or preparation area. Fire extinguisher was last purchased on 01/16/2024. Refrigerator and freezer were within the required temperatures. The first aid supplies were complete, including a thermometer. The first aid kit is located in a cabinet in the kitchen area medications will be stored in locked cabinet located in the kitchen. Continues on LIC 809 C... BEDROOMS: Facility has three (3) bedrooms for resident use. There is no bedroom available for staff use. Bedrooms are for double occupancy. Bedroom #3 is approved for one (1) bedridden resident. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing and personal belongings. The supply of linens is sufficient to permit changing weekly or more often as needed to ensure change of linens at all times. BATHROOMS: The facility has two bathrooms. Bathrooms are fully stocked with paper towels, and liquid hand soap. The showers have non-skid surface mats. Hot water temperatures were recorded in Fahrenheit degrees as follows:117.6 degrees for bathroom #1, and 118.2 degrees for bathroom in bedroom #3. Hand washing signs were visible and posted. OUTDOOR AREA/GARAGE: The back patio is furnished with outdoor furniture for residents’ use, and shade is available. Fire emergency gates are clear of obstructions. The facility has a gated pool, and is inaccessible to residents. The garage is detached from the facility. The laundry area is located inside the garage.. RECORDS: Records review began at 1:30 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 2:09 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 31, 2024