Inspection Reports for Stellar Care

An unannounced required one-year inspection was conducted to evaluate compliance with licensing requirements at the facility.

The facility was found to be in full compliance with no deficiencies observed or cited. The environment, supplies, food storage, medication management, and records were all in proper order.

An unannounced complaint investigation was conducted following allegations that staff did not communicate with a resident's responsible party regarding care and that staff were not properly supervising a resident who is a fall risk.

The investigation found that communication between staff and the resident's responsible party occurred frequently and appropriately, and staff were properly supervising the resident at fall risk with adequate training and care plans. The allegations were deemed unsubstantiated.

The complaint involved two allegations: 1) staff not communicating with the responsible party regarding resident's care, and 2) staff not properly supervising a resident who is a fall risk. The investigation found no substantiation for these allegations.

An unannounced complaint investigation visit was conducted in response to an allegation of lack of supervision resulting in resident eloping.

The investigation included file review and staff interviews, revealing that Resident #1 can leave the facility unassisted without restriction. The complaint was found to be unfounded.

The complaint alleging lack of supervision resulting in resident eloping was investigated and found to be unfounded based on staff interviews and records review.

The inspection was conducted as an unannounced complaint investigation following an allegation received on 04/04/2025 that staff did not respond to residents' call light requests in a timely manner.

The investigation found the allegation unsubstantiated based on interviews with staff, residents' family members, an outside source, and direct observations. Staff were observed responding promptly to call light requests with average response times between 1.8 and 3.5 minutes.

The complaint alleged that staff did not respond for thirty minutes to call light assistance and failed to return after initially responding. The investigation did not corroborate this allegation and deemed it unsubstantiated.

The visit was conducted in response to an Incident Report submitted for Resident 1 who sustained a fall resulting in a femoral neck fracture and subsequent hospitalization.

The Licensing Program Analyst reviewed Resident 1's records and interviewed staff, identifying no health and safety concerns and citing no deficiencies during the visit.

The visit was triggered by an incident involving Resident 1's fall on 2025-03-27, which resulted in a femoral neck fracture and hospitalization. The resident was transferred to a rehabilitation facility and will not return due to the need for a higher level of care. No deficiencies were cited and no health and safety concerns were found.

An unannounced complaint investigation was conducted due to an allegation that staff left a resident in a soiled diaper for a long period of time.

The investigation included a facility tour, record review, staff interviews, and outside source confirmation. The allegation was found to be unsubstantiated based on the preponderance of evidence.

The complaint alleged that staff left Resident #1 in a soiled diaper for a long period. The investigation found that an incontinence schedule was followed, and outside sources confirmed no concerns. The allegation was deemed unsubstantiated.

An unannounced complaint investigation visit was conducted in response to allegations that staff did not prevent residents from engaging in inappropriate interactions and did not prevent a resident from verbally harassing another resident in care.

The investigation included interviews, records review, and a facility tour. Staff were found to intervene appropriately to prevent inappropriate interactions and protect residents' rights. The allegations were determined to be unsubstantiated as the preponderance of evidence standard was not met.

The complaint was unsubstantiated based on contradictory statements and evidence showing staff intervention to prevent inappropriate interactions and protect resident rights.

An unannounced complaint investigation was conducted in response to an allegation that the licensee did not allow a resident to have visitors.

The investigation found that the resident does have a visitor restriction due to the visitor being disruptive and posing a threat. The licensee communicated visitation policies clearly and worked with the resident's responsible party to establish supervised visits. Telephone communication was not restricted. The allegation was deemed unsubstantiated based on interviews and records review.

The complaint alleged that the licensee did not allow a resident to have visitors. The allegation was investigated and found unsubstantiated.

The unannounced visit was conducted to discuss the Executive Director Brandon Cho's request for a change in capacity from 120 to 150 non-ambulatory residents.

The inspection found the living accommodations and grounds to be in compliance with Title 22 regulations for an increase in capacity. The physical plant was consistent with the submitted facility sketch/floor plan.

An unannounced case management visit was conducted to follow up on an incident involving Resident 1 who experienced an unwitnessed fall and subsequent death.

The facility acted appropriately and in compliance with regulations regarding the incident. Staff followed emergency protocols, and no deficiencies were cited during the visit.

The visit was triggered by an incident report concerning Resident 1's fall on October 30, 2024, and subsequent death on November 10, 2024. The complaint was investigated and found to be unsubstantiated as the facility complied with all applicable regulations.

An unannounced complaint investigation was conducted due to an allegation that staff do not ensure that residents' dietary needs are met.

The investigation included interviews, record reviews, and observations of meal service. It was found that the facility accommodates special and preferred diets for 31 of 103 residents, with no concerns noted in the last dietitian report. The allegation was deemed unsubstantiated based on the evidence.

The complaint alleged that staff do not ensure residents' dietary needs are met. After investigation, including interviews with staff and outside sources, record reviews, and meal observations, the allegation was found unsubstantiated.

An unannounced complaint investigation was conducted in response to an allegation that licensee staff handled a resident roughly.

The investigation included interviews with residents, staff, outside sources, and review of facility records. The allegation was determined to be unsubstantiated as no evidence of rough handling was found and the resident reported feeling safe and comfortable.

The complaint alleged that licensee staff handled a resident roughly. The investigation found that the resident was combative and staff used non-threatening redirection. No injuries or rough handling were observed or reported. The allegation was unsubstantiated.

The visit was conducted in response to a licensee self-submitted report involving Resident #1, concerning an x-ray revealing a fracture in the right foot of unknown origin.

No deficiencies were cited related to the incident or observed during the visit. The resident's latest medical x-ray showed no acute fracture, chip, or dislocations, and no safety concerns were found during the welfare check.

The complaint was based on a licensee self-submitted report about Resident #1's foot fracture. The investigation found no substantiated deficiencies.

The visit was a case management visit conducted due to a request to increase the facility waiver capacity for hospice care.

During the visit, the Licensing Program Analyst toured the facility and observed a client in care. No immediate health or safety concerns were observed.

Licensing Program Analyst Amy Rodgers conducted an unannounced required One-Year Inspection of the facility.

The inspection found the facility to be in compliance with all licensing requirements. Resident rooms, bathrooms, and common areas were clean and properly equipped. Food and medication storage were appropriate, and staff interviews and record reviews revealed no significant concerns. No deficiencies were cited.

An unannounced complaint investigation was conducted following a complaint alleging staff neglect resulted in wounds to a resident.

The investigation substantiated the allegation that staff neglect led to wounds on Resident 1, including shoulder and hip abscesses and cellulitis. The facility failed to provide sufficient competent personnel to meet the resident's needs, and there was a delay in notifying supervision of the wounds.

The complaint was substantiated based on evidence gathered during record review and interviews. The allegation involved staff neglect causing wounds to Resident 1, who was found with lesions and later treated for MRSA. The preponderance of evidence standard was met.

An unannounced Case Management visit was conducted to amend a prior complaint investigation report and discuss the changes with the licensee.

No deficiencies were observed or cited during the visit. The licensee agreed to remove any copies of the prior report and replace them with the amended report.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-11-22 regarding medication administration issues at the facility.

Two allegations were investigated: one regarding failure to administer medication as prescribed, which was unsubstantiated, and another regarding medication being accessible to a resident, which was substantiated. The facility conducted an internal investigation, initiated medication re-training for staff, and self-reported the incident.

The complaint investigation was initiated due to allegations that the licensee did not administer medication as prescribed and did not ensure medication was inaccessible to a resident. The first allegation was unsubstantiated; the second was substantiated with deficiencies cited.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-10-27 regarding fee increase notice, unlawful fees, resident assessment, shower cleanliness, and food service requirements.

The investigation found no substantiation for the allegations after staff interviews, records review, direct observations, and outside source interviews. The facility complied with notification requirements for fee increases, assessments were timely and appropriate, showers were clean according to schedule, and food service met quality and variety standards.

The complaint included allegations that the licensee did not provide a 60 day notice of fee increase, charged unlawful additional fees, failed to assess a resident for a higher level of care, did not ensure a resident's shower was clean, and did not meet food service requirements. The investigation concluded these allegations were unsubstantiated.

An unannounced complaint investigation was conducted in response to allegations that staff did not treat a resident with dignity and respect and did not meet the resident's dietary needs.

The investigation included observations, record reviews, and interviews with staff, residents, and outside sources. There was insufficient evidence to substantiate the allegations, and it was found that staff were aware of and took precautions to meet the resident's dietary needs.

The complaint alleged that staff told a resident they needed to eat what was served or starve, and that the resident's dietary needs were not met due to allergies. The investigation found no evidence of mistreatment or failure to meet dietary needs; the resident's allergies were clearly communicated and accommodated, and alternative meal choices were offered. The resident's claim of diabetes was inaccurate according to medical records.

The inspection was conducted as an unannounced complaint investigation following a complaint alleging that staff did not meet a resident's toileting needs.

The investigation included observations, record reviews, and interviews with residents, staff, and outside sources. The allegation was found to be unsubstantiated as residents and outside sources reported no issues, and records showed no lapse in incontinent care.

The complaint alleged that a resident was not receiving timely toileting assistance from staff. The investigation failed to produce evidence to support the allegation, and it was deemed unsubstantiated.

The inspection was an unannounced complaint investigation triggered by an allegation of lack of supervision resulting in inappropriate behavior between residents.

The investigation included interviews with staff and residents, a facility tour, and record review. The allegation that Resident #2 entered Resident #1's bedroom and got into bed without consent was not substantiated due to inconsistent statements and lack of corroborating evidence.

The complaint alleged lack of supervision leading to inappropriate behavior between residents. The allegation was found unsubstantiated after investigation.

An unannounced required 1-year visit was conducted to evaluate the facility's compliance with licensing requirements and infection control protocols.

No deficiencies were cited or observed during the inspection. The Licensing Program Analyst provided technical assistance and evaluated the facility's infection control mitigation plan including disinfection, testing surveillance, screening protocols, and use of personal protective equipment.

The inspection was an unannounced complaint investigation visit triggered by allegations that a resident sustained a fracture due to lack of supervision and that the facility did not seek medical care for the resident.

The investigation found no corroborating evidence to substantiate the allegations. Although the resident had a fracture and bruising, there was no documentation or knowledge of a fall, and medical care was sought appropriately. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint involved allegations that Resident1 sustained a fracture from neglect and lack of supervision and that medical care was not sought. The investigation included interviews and record reviews. The findings were unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation that a resident sustained a fracture while in care due to lack of supervision.

The investigation found insufficient evidence to substantiate the allegation that the resident's fracture was caused by lack of supervision. Interviews, record reviews, and other evidence did not corroborate the claim, resulting in an unsubstantiated finding.

The complaint alleged that Resident1 sustained a hip fracture from an unwitnessed fall due to lack of supervision. The investigation included interviews with staff and review of records. Resident1 reported being pushed down by Resident2, who denied it. No staff witnessed the fall or Resident2 entering Resident1's room. The facility camera footage was not reviewed. Resident1 required surgery and was discharged with new care orders. Resident2 was transferred for psychiatric evaluation and did not return. Due to lack of corroborating evidence, the allegation was unsubstantiated.

An unannounced complaint investigation was conducted due to allegations that the facility refused to accept residents back after hospitalization.

The investigation found insufficient evidence to substantiate the allegation that residents were refused re-admission after hospitalization. Records and interviews showed residents were either returned or safely relocated with proper communication with the Regional Office.

The complaint alleged that Resident 1 and Resident 2 were not allowed to return to the facility after hospitalization with positive COVID-19 diagnoses. The investigation concluded the allegation was unsubstantiated due to lack of corroborating evidence.

The inspection was an unannounced Required 1-Year Visit to evaluate the facility's compliance with licensing regulations and infection control measures.

The Licensing Program Analyst conducted a tour and review of the facility, including evaluation of the COVID-19 Mitigation Plan. No deficiencies were cited during this inspection.

Licensing Program Analyst Dang Nguyen conducted a case management visit to provide technical assistance regarding COVID-19. The visit was conducted via video telephone call due to the pandemic.

During the visit, the analyst toured the facility and provided consultation regarding the facility’s COVID-19 Mitigation Plan. No deficiencies were cited during the visit.