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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608611
Report Date: 10/29/2021
Date Signed: 10/29/2021 03:29:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ESTAR RESIDENTIAL CAREFACILITY NUMBER:
197608611
ADMINISTRATOR:ARNALDO A. HUKOMFACILITY TYPE:
740
ADDRESS:8559 BOTHWELL ROADTELEPHONE:
(818) 727-1953
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 1DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Herminia LazoTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required annual visit. LPA was greeted by staff Herminia Lazo. Administrator was called by phone. and was on the way, Observation of arrival. There is a table that has hand sanitizer, and wipes . The sanitizer is not a clear consistency and cloudy in color. The LPA asked the staff if they make their own hand sanitizer. The staff could not answer. Upon entry no screening was done of LPA. Esperanza Hokom was contacted by phone and was on her way to the facility.

The LPA asked the staff questions and also attempted to interview the one resident. During the visit LPA checked the thermometer and had staff show her the log in sheet. The visitor log has not been updated since 10-1`2-2021. Staff does not log their temperature and no surveillance testing is done for the staff. Staff did show proof of their vaccination and booster. The administrator arrived and was informed about the information on the Mitigation plan that they said they would follow. Administrator started a log for staff to document temperatures The screening questionnaire will be updated and available when visitors arrive at the home.

No citations issued. Exit interview conducted.






SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Angelica ArambuloTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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