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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201133
Report Date:
03/02/2022
Date Signed:
03/02/2022 02:51:30 PM
Document Has Been Signed on
03/02/2022 02:51 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 HOME
FACILITY NUMBER:
019201133
ADMINISTRATOR:
ONWURAH, ANNETTE
FACILITY TYPE:
735
ADDRESS:
1429 57TH AVE
TELEPHONE:
(510) 260-9865
CITY:
OAKLAND
STATE:
CA
ZIP CODE:
94621
CAPACITY:
6
CENSUS:
0
DATE:
03/02/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
02:05 PM
MET WITH:
Annette Onwurah, Administrator
TIME COMPLETED:
02:55 PM
NARRATIVE
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LPAs Greg Clark and Laura Hall conducted a face to face Component III presentation on 03/02/22 starting at 2:05 p.m. LPAs met with licensee and administrator Annette Onwurah.
LPAs presented Component III power point and discussed the regulations embodied in the power point. LPA observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.
Exit interview conducted with Annette Onwurah a copy provided.
SUPERVISORS NAME
:
Yvonne Flores-Larios
LICENSING EVALUATOR NAME
:
Gregory Clark
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/02/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/02/2022
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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