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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201133
Report Date: 05/22/2024
Date Signed: 05/22/2024 03:14:22 PM

Document Has Been Signed on 05/22/2024 03:14 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:
05/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Ike Onwurah, House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 5/22/24 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Ike Onwurah, House Manager and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathroom, common area, kitchen, and outdoor area. Hot water temperature in the kitchen was measured at 107.5 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in the medication cabinet. Smoke detectors and Carbon monoxide detector observed to be in operating condition. Fire extinguisher was observed to be operational during visit. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

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: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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