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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201133
Report Date: 12/17/2024
Date Signed: 12/17/2024 06:32:51 PM

Document Has Been Signed on 12/17/2024 06:32 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: 3DATE:
12/17/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:50 PM
MET WITH:Annette Onwurah, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
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On 12/17/2024 at 5:50pm, Licensing Program Analysts (LPAs), L. Hall and L. Holmes arrived unannounced to conduct a health and safety check LPA met with Annete Onwurah, Administrator, and explained the reason for the visit.

Upon arrival LPAs observed one (1) client and one (1) staff in addition to Administrator.

During the health and safety check, LPA toured the facility including but not limited to common areas, bathrooms, bedrooms and outdoor area. LPA observed one (1) sleeping and one (1) client was relaxing in his room. The facility is noted to be clean, in good repair, and clients in care appear to be safe. There is a minimum of 7-day non-perishables and 2-day perishables foods. There are no imminent health/safety concerns on today's date.

LPAs obtained a copy of the personnel report (LIC500).

No deficiencies were cited today.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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