Starlight Care Home

Plan of Operation. The licensee shall have and maintain a current, written definitive plan of operation for the facility....Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met evidenced by: Based on record review and interviews, Licensee has not submitted an updated Plan of Operation that includes and addresses the physical plant changes made i.e., a former resident room (rm #3) is now the live-in staff room. This poses a potential health, safety, or personal rights risk to persons in care.

Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: 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 was not met evidenced by: Based on observation, a Vitamin B-12 1,000 mcg was observed unlocked in the living room and Allergy Relief Antihistamine 10 mg was observed unlocked in staff room. This poses an immediate health, , safety or personal rights risk to persons in care.

Postural Supports. 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.This requirement was not met evidenced by: Based on observation, the licensee did not comply with the section cited above in that (R1) is not enrolled in hospice and their bed had full bed rails, which poses an immediate health, safety or personal rights risk to persons in care.

Plan of Operation. The licensee shall have and maintain a current, written definitive plan of operation for the facility....Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met evidenced by: Based record review, the Licensee did not submit the following items agreed upon during the 9/17/2025 NCC meeting: written plan, updated Plan of Operation and updated facility sketch addressing live-in staff accommodations. This poses a potential health, safety or personal rights risk to persons in care.

Maintenance and Operation. 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 was not met evidenced by: Based on observation, the facility interior and exterior physical plant is not clean and sanitary. All facility floors were dirty, kitchen counters and floors were dirty, and discarded furniture was observed in the backyard & garage. This poses a potential health, safety or personal rights risk to persons in care.

Personal Accommodations and Services. Living accommodations and grounds shall be related to the facility's function. The facility .... provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement was not met evidenced by: Based on observation and interviews conducted, live-in staff (S2) is sleeping in the living room, and live-in staff (S3) sleeps in the garage. This poses a potential health, safety or personal rights risk to persons in care.

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. Based on observation, there was a pair of unlocked scissors in resident (R1's) bedroom #1, unlocked knives and cleaning solutions in kitchen cabinets, and unlocked personal hygiene solutions stored in the living room, which poses an immediate health, safety or personal rights risk to persons in care.

Criminal Record Clearance. (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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) orThis requirement is not met as evidenced by: This requirement was not met evidenced by:Based on file review S1 was hired on 11/3/25, has criminal record clearance, but is not associated to the facility; which poses an immediate health, safety or personal rights risk to persons in care.

Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator.... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section.... Based on observation and staff interviews, Licensee left on vacation out of the country on Nov. 11, 2025, and did not submit to CCL LIC 308 Designation of Facility Responsibility appointing new staff as a facility representative. This poses a potential l health, safety or personal rights risk to persons in care.

Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: A health screening as specified in Section 87411, Personnel Requirements - General. This requirement was not met evidenced by: Based on record review, staff (S1) was hired on 11/3/2025. Their file documents do not include a completed health screening/TB clearance. This poses a potential health, safety or personal rights risk to persons in care.

Based on observation, LPA Ramirez observed bathroom cabinet drawer in bedroom#3 to be in disrepair and exposing sharp screws. the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, licensee could not provided liability insurance upon request, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, 3 out of the 3 staff employed do not have proof of CPR and first aid training in their files, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, no fire drills are documented, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interview, staff are disgarding used lancets in garbage can, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, LPA Ramirez observed 2 disgarded hospital bed frames blocking passageway access to from bedroom#3, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observations, R1 had access to disinfectant wipes in their room, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, R1 had access to supplements in their room, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, R3, R4 and R5 did not have medical assessments in their file, the licensee did not comply with the section cited above in 3 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, R3 and R6 did not have appraisals in their files, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interviews, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, licensee's poster is not 20"x26", the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that the knives and sharps cabinet in the kitchen was unlocked, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that it failed to keep/provide a copy of emergency drills in facility file. This poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that resident (R5’s) medications were observed to be unlocked on a pill container on top of the dining table, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that Licensee/Administrator does not have any centrally stored medication records and/or Medication Administration Records (MAR's) for any of the residents in care. Staff are administering medications in pill bottles & bubble pack medications without physician orders and centrally stored records, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in licensee/Administrator terminated telephone land line services in 2024, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that resident (R6's) bed does not have a matress pad, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that LPA observed live-in staff (S2) sleeps in the garage. In addition, live- in staff (S3) sleeps in the living room and has their belongings in the garage, which poses a potential health, safety or personal rights risk to persons in care. Pictures were taken.

Based on observation, the licensee did not comply with the section cited above in that a total of 2 out of 4 resident rooms inspected did not have smoke detectors with batteries, which poses an immediate health, safety or personal rights risk to persons in care. * Pictures were taken.

Based on record review, the licensee did not comply with the section cited above in that Licensee/Administrator does not have any centrally stored medication records and/or Medication Administration Records (MAR's) for any of the residents in care. Staff are administering bubble pack medications without physician orders and centrally stored records, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that residents (R3 & R4) do not have admission reports, appraisals, and any files on the residents. Both residents were admitted 8/14/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that one (1) canned food container was heavily damaged and 7 expired can food items were in the food pantry, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that kitchen knives/sharps/scissors were unlocked in the kitchen and an additional pair of scissors were observed unlocked in the living room shelf next to incontinence supplies, which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above in that Liability Insurance is expired and there is no current policy in place, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that the facility does not have a carbon monoxide detector; which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above in that a fire/emergency drill has not been conducted since late 2019, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that LPA observed live-in staff (S2) sleeps in resident room # 3 which is designated as a resident room. In addition, llive- in staff (S3) sleeps in the living room and has their belongings in the garage; which poses/posed a potential health, safety or personal rights risk to persons in care. Pictures were taken.

Based on observation, the licensee did not comply with the section cited above in that none of the resident beds have mattress pads, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that staff files do not have proof of current staff training, and at least of 4 hours of annual training, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that resident R4 does not have an MD report and Dementia R2 has a MD report that is not updated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that resident medications were observed to be unlocked in the kitchen cabinet and a bubble pack was on top of the dining room table at the beginning of the visit, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that Administrator has not developed an Infection Control Plan (ICP),which poses/posed a potential health, safety or personal rights risk to persons in care.

Postural Supports. Postural supports may be used under the following conditions. 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. This requirement was not met evidenced by: On 3/30/22 a visitor observed all resident beds had full-length bedrails that were not securely attached to the bed. However, there are presently no residents receiving hospice services. This poses a potential health, safety or personal rights risk to persons inhealth, safety or personal rights risk to persons in care.

General Food Service Requirements. The following food service requirements shall apply: All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.This requirement was not met evidenced by: Based on observation and picture proof evidence on 3/30/22 a visitor observed dry goods packaging had holes and evidence of cockroach consumption. This poses a potential health, safety or personal rights risk to persons in care.

General Food Service Requirements. The following food service requirements shall apply: All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.This requirement was not met evidenced by: Based on observation and picture proof evidence at least 20 cockroaches and several hundred cockroach eggs were observed in kitchen cabinets, food storage area, utensils, and cabinet storage areas. This poses an immediate health, safety or personal rights risk to persons in care.

General Food Service Requirements. The following food service requirements shall apply: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.This requirement was not met evidenced by: On 3/30/22, a visitor did not observe two days' worth of perishable/fresh food meals. Staff confirmed that they did not have sufficient 2-day supply of food on that day. This poses a potential health, safety or personal rights risk to persons in care.

General Food Service Requirements. The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents..... All food shall be selected, stored, prepared and served in a safe and healthful manner.This requirement was not met evidenced by: Based on observation, on 3/30/22 the facility had expired canned good on shelves. Staff interviews confirmed the allegation. This poses a potential health, safety or personal rights risk to persons in care.

Maintenance and Operation. 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 was not met evidenced by: Based on photo evidence the wood ramp at facility entrance is warped and poses a tripping/fall hazard to residents in care, staff, and visitors. The front and backyard lawns had overgrown grass, floors and refrigerator were dirty. This poses a potential health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: 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 was not met evidenced by: On 3/30/22 a visitor observed the medication cabinet was not locked. Staff were not able to lock it during the visit. During today's visit, LPA observed the cabinet to be locked. This poses an immediate health, safety or personal rights risk to persons in care.