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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607901
Report Date: 06/12/2026
Date Signed: 06/12/2026 03:58:05 PM

Document Has Been Signed on 06/12/2026 03:58 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:STARLIGHT CARE HOMEFACILITY NUMBER:
197607901
ADMINISTRATOR/
DIRECTOR:		ANA F. DUENASFACILITY TYPE:
740
ADDRESS:1704 KERRY COURTTELEPHONE:
(626) 824-6343
CITY:WEST COVINASTATE: CAZIP CODE:
91792
CAPACITY: 6CENSUS: 5DATE:
06/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Andrew Escobar, Facility DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) N. Galarza arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation. LPA was greeted and granted entry by caregiver staff Antonio Santiago. Facility Designee Andrew Escobar arrived shortly after. Administrator has a valid administrator's certificate expiring on 7/26/2027.

The following was observed during the inspection:

Infection Control: The facility has an Infection Control Plan.

Operational Requirements: A Dementia and hospice waiver for 3 residents has been approved. A fire clearance for 5 non-ambulatory and 1 bedridden in room #3. The facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 9/11/2026.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The facility is a single-story home located in a residential area consisting of three (3) shared resident bedrooms, one (1) live-in staff room, two (2) bathrooms, kitchen, dining room, living room,and laundry area in attached 2-car garage currently used as storage. The backyard has an covered patio and storage shed in the rear of the backyard. The front and backyards are landscaped with grass. Required furniture, bed mattress pads, and linens were observed. Cleaning supplies and toxic substances are inaccessible to residents. The facility has two fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Electrical smoke and carbon monoxide detectors were tested and are operational. The home has central heating & air conditioning. Comfortable temperature for residents is maintained. Exit doors are free of any obstruction and there are no pools. No record of Emergency Disaster drill was provided. A citation was issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2026
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901
VISIT DATE: 06/12/2026
NARRATIVE
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Staffing: A total of 2 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Staff have criminal background clearance and training. Three (3) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training is current.

Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Orders, and medical consent. All resident files are missing Appraisal Needs and Service Plans and R1's medical assessment is blank, R2's is dated 9/13/2023, R3's is dated 7/12/2024, R4's is dated 10/21/2024, R5's is dated 10/8/2025 but is incomplete. Citations were issued.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have modified diets.

Incident Medical and Dental: Three (3) centrally stored / 30-Day supply of medications were reviewed. Medical and dental transportation is provided by family.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. The facility has a First Aid Kit and Manual consisting of thermometer, tweezers, scissors, antiseptic, bandages, gauze.

Residents with Special Health Needs: Two (2) residents receives hospice services and three (3) residents receive home health services. One resident is bedridden in room 3.

Pursuant to California Code of Regulations, Title 22, deficiencies were cited.



An exit interview was conducted with Facility Designee Andrew Escobar. A copy of the report and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/12/2026 03:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/12/2026 at 03:22 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above because none of R2's medications have been filled, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2026
Plan of Correction
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Administrator shall fill all of R2's medications by tomorrow. Submit pictures of the medications and staff in-service training.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/12/2026 03:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/12/2026 at 03:22 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above because all 5 resident files were missing Appraisal Needs and Services Plans, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Administrator/Licensee shall submit copies of all resident LIC 625 Appraisal Needs and Services Plans.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above; R1's medical assessment is blank, R2's is dated 9/13/2023, R3's is dated 7/12/2024, R4's is dated 10/21/2024, R5's is dated 10/8/2025 but is incomplete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Administrator/Licensee shall submit updated LIC 602A Medical Assessments for residents (R1-R5).
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2026 03:58 PM - It Cannot Be Edited


Created By: Noemi Galarza On 06/12/2026 at 03:37 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: STARLIGHT CARE HOME
FACILITY NUMBER: 197607901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above because there was no record that emergency disaster drill have been conducted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Administrator/Licensee shall submit proof that a drill was conducted.
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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2026


LIC809 (FAS) - (06/04)
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