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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201133
Report Date: 04/27/2023
Date Signed: 04/27/2023 12:30:39 PM

Document Has Been Signed on 04/27/2023 12:30 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:ONWURAH, ANNETTEFACILITY TYPE:
735
ADDRESS:1429 57TH AVETELEPHONE:
(510) 260-9865
CITY:OAKLANDSTATE: CAZIP CODE:
94621
CAPACITY: 6CENSUS: 0DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Annette Onwurah, AdministratorTIME COMPLETED:
12:40 PM
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On 4/27/23 at 11:05 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Annette Onwurah, Administrator and explained the purpose of the visit. The facility’s fire clearance was approved for 6 ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms of which all bedrooms are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the kitchen was measured at 110.2 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene were available for clients. There are no clients currently at the facilty.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 4/24/23. First aid kit was observed to be complete.

No residents at the facility at this time.

No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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