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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201133
Report Date: 01/10/2025
Date Signed: 01/10/2025 03:19:36 PM

Document Has Been Signed on 01/10/2025 03:19 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: DATE:
01/10/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Annette Onwurah, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 1/10/24 at 1:00 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver amended complaint investigation report for complaint #15-AS-20240910135724. LPA met with Administrator, Annette Onwurah and explained the purpose of the visit.

During the course of the visit LPA interviewed residents and staff and delivered amended report.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2025
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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