GOLDEN STAR HOME

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 02/27/2026 Plan of Correction 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

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 03/05/2026 Plan of Correction 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.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 03/05/2026 Plan of Correction 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.

Official classification

Type A

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 04/23/2025 Plan of Correction 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.

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 04/23/2025 Plan of Correction Facility to submit pictures of installed and operational smoke alarms and carbon monoxide detectors by plan of correction due date 4/23/25.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 04/23/2025 Plan of Correction 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.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 04/23/2025 Plan of Correction Facility to submit LIC9098, self certifying all medications will remain inaccesible to residents by POC 4/23/25

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction 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

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 04/29/2025 Plan of Correction Facility to submit completed training records and the number of hours required by regulation by POC due date 4/29/25

Official classification

Type B

Official code

87219(i)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction 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

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction Admin immedietly discared all spoiled food items, expired items and rice. Deficency cleared

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

(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 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

Official plan of correction

POC Due Date: 04/29/2025 Plan of Correction Facility to submit LIC9098 seld certifing facility will remain free of incontinence odors by plan of correction due date 4/29/25

Official classification

Type B

Official code

1569.5

Regulation authority

HSC

What the official deficiency says

§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.

Official 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.

Deadline recorded: Mar 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

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.

Deadline recorded: Mar 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Mar 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(g)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

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

Deadline recorded: Mar 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above because the front door has a latch that is attached to the door frame and extends over the door and has key that requires it to be opened. The front and back door both have a latch that is attached to the door frame and when pushed up is able to cover part of the front door and then pushed down which locks it in place but does not require a lock. Both prevents residents from exiting which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2024 Plan of Correction By 04/16/2024, the licensee shall remove the lock and latches from the doors and submit proof to Community Care Licensing Division along with a written statement stating how they shall prevent it from occuring again.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above because the front door's audio alarm is turned off which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2024 Plan of Correction Licensee shall submit a written plan of correction on how they shall ensure audio alerts are turned on and how they shall monitor the audio alerts.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2024 Plan of Correction By 05/15/2024, Licensee shall submit a written plan of correction on how they shall ensure people who have a diagnosis of dementia shall have an annual medical assessment.

Official classification

Type B

Official code

87705(c)(6)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement cited in error

Official plan of correction

POC Due Date: 04/15/2024 Plan of Correction cited in error. no deficency

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(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 Based on interviews with both staff members, LPA learned that the licensee did not comply with the section cited above due to the facility not conducting an Emergency Disaster Drill this year. This regulation poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/04/2023 Plan of Correction Licensee shall submit a Plan of Correction that will include a date for the next Emergency Diaster Drill, retain documentation and provide a statement on how future compliance will be met.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c.. This requirement is not met as evidenced by: Deficient Practice Statement Based on today's inspection and review of The Guardian, the licensee did not comply with the section cited above in 2 out of 2 individuals residing in the home did not have the proper fingerprint transfer association to this facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2022 Plan of Correction Facility agrees to submit the required paperwork to CCL to associate both individual to facility. POC due date 4/25/2022. Administrator/Licensee to ensure that all staff have criminal record clearance with DOJ & FBI & are associated to the facility prior to residing or working in the facility.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

87465 (a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. Facility staff failed to give residents' their medications as ordered/prescribed by the Physician. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and interviews R1 missed two dosages of medication which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

POC Due Date: 04/27/2022 Plan of Correction Adminstrator will audit all resident's medication and update resident's centrally stored logs and ensure staff are properly distrubuting medication. Facility to send LPA copy of updated centrally stored log, that includes start dates of medication by POC due date 4/27/22.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services Basic services shall at a minimum include: (1) Care & supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not provide care and supervision for R2.which posed an immediate risk to health and safety.

Official plan of correction

Administrator to submit a self certfication that they have reviewed regulation regarding Care and Supervision and submit plan to CCL attention LPA Katrina Walters.

Deadline recorded: Jun 24, 2021. A deadline is not proof that correction was completed.