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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201133
Report Date: 12/19/2024
Date Signed: 12/19/2024 05:22:50 PM

Document Has Been Signed on 12/19/2024 05:22 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NORTH STAR RESIDENTIAL HOMEFACILITY NUMBER:
019201133
ADMINISTRATOR/
DIRECTOR:		ONWURAH, ANNETTEFACILITY TYPE:
735
ADDRESS:1429 57TH AVETELEPHONE:
(510) 260-9865
CITY:OAKLANDSTATE: CAZIP CODE:
94621
CAPACITY: 6CENSUS: 3DATE:
12/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Annette Onwurah, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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On 12/19/24 at 4:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit. Administrator Annette Onwurah arrived at 5:15 p.m. LPA explained the purpose of the visit.

LPA went to the facility to deliver an Immediate Exclusion letter for S1. It was confirmed S1 was not present at the facility. Immediate Exclusion letter was delivered for S1 and notification of the exclusion letter was given to the administrator. LPA has advised the administrator to disassociate the individual from their roster and submit an updated LIC 500.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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