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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608611
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:46:19 PM

Document Has Been Signed on 08/02/2022 04:46 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, 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: 4DATE:
08/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Arnaldo HumkomTIME COMPLETED:
04:50 PM
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On 03/22/22, LPA Tihesha Lynn Smith conducted a case Management Visit in conjunction with complaint investigation to address the issues unrelated to the complaint. At the time of Case Management visit LPA spoke with Arnaldo and Esperanza Humkom (administrators) and informed that during Licensing Visit the following deficiencies were observed and cited:

Medication storage area was left unlocked. Staff locked the medicine cabinets. Therefore, this citation cleared during the visit.

A female staff #2 (S2) who was performing Covid protocols by checking LPA temperature is not associated with the facility. Immediate civil penalty assessed for 100.00 max as S2 was present at the facility for one day.

Bathroom (located to the right of the main entry door) has a large piece of the sink countertop missing on the corner edge and drywall at bottom of wall next to side of toilet is peeling, warped, and needs repair.

On 04/08/22 and 04/11/2 LPA Smith received photo verification that items cited had been repaired. LPA’s review of sink repair photo revealed that an irregular piece was used to cover sink corner still posed potential hazard due to edges sticking out. Administrator Hukom revealed he would have contractor review repair and replace countertop.

During today’s visit, LPA Smith conducted tour of the facility and observed the following: the medication cabinet observed to be locked an inaccessible to residents, the bathroom has brand new countertop, and drywall next to toilet repaired.

All deficiencies previously cited on 03/22/22, are cleared at time of this visit.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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