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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201133
Report Date: 04/26/2024
Date Signed: 04/26/2024 03:09:09 PM

Document Has Been Signed on 04/26/2024 03:09 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: 2DATE:
04/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Ike onwurah, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 4/26/24 at 2:45 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit on this date due to receiving a Special Incident Report (SIR) that stated a resident had passed way. LPA met with Ike Onwurah, Administrator and explained the purpose of the visit.

LPA received a SIR dated 4/02/24 that while out in the community with his girlfriend R1 got into an altercation with some people and was stabbed. R1 later passed away at the hospital (Eden Medical Center) from his injuries.

Sign out log indicated that on 4/02/24 R1 left the facility at 10:56 a.m., to meet up with his girlfriend.

LPA reviewed R1 Physicians Report dated 10/25/23 which documented that R1 was able to leave the facility unassisted.

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: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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