198320227-3-2-2022-11-AS-LMOA-CC5V5E-20220302150749

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320227
Report Date: 03/01/2022
Date Signed: 03/02/2022 03:08:07 PM

Document Has Been Signed on 03/02/2022 03:08 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	STAR HOUSE 5		FACILITY NUMBER:	198320227
ADMINISTRATOR:	BRODERICK, PAMELA		FACILITY TYPE:	735
ADDRESS:	2719 EL DORADO STREET		TELEPHONE:	(310) 542-8895
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 5		CENSUS: 5	DATE:	03/01/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Pamela Broderick		TIME COMPLETED:	05:00 PM

NARRATIVE

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On 3/1/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an announced visit to this home. LPA was greeted by Applicant Pamela Broderick and explained the purpose of today’s pre-licensing inspection visit.

An application was submitted to CCLD on 9/22/2021 for a Change of Ownership application for an Adult Residential Facility. The applicant requested a capacity of five (5) individuals.

Structure:
The facility is a one-story house with a basement located in a residential neighborhood and consists of three (3) bedrooms, three (3) bathrooms and a two (2) car garage on the first floor; kitchen, living room, dining room and a patio; the basement consists of a bathroom and office/storage. The facility is clean, sanitary, and in good repair. Protective devices are in place to include non-slip material on rugs. Indoor and outdoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 68 degrees and 85 degrees.

Bedrooms (Residents):

The facility has three (3) bedrooms for ambulatory clients. All rooms include (1) a bed, one (1) chair, one (1) nightstand, one (1) table lamp. No client bedroom is a passageway to another room, bath, or toilet.

Bedrooms (Staff):

There is one bedroom with an ensuite bathroom for staff.

Bathrooms:
The home has two (2) bathrooms on the first floor for residents, a bathroom in the staff bedroom and one bathroom in the basement. All resident bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Evaluation Report Continues

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: STAR HOUSE 5	FACILITY NUMBER: 198320227
	VISIT DATE: 03/01/2022

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Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the hall closet adjacent to the client’s bedrooms and bathroom.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There are four (4) fire extinguishers located in the kitchen, in the hallway near the resident bedrooms, in the basement, and in the garage mounted, all were on the wall; the fire extinguisher in the staff room is not mounted. A telephone line is available in the kitchen (310-533-8078). Emergency supplies and Personal Protective Equipment supplies are stored in the basement.

Food Service:
All kitchen areas are clean and free of litter, rodents, vermin, and insects. The refrigerator and freezer are clean and of adequate size. The freezer is maintained at 0 degrees Fahrenheit and the refrigerator is below the required maximum of 40 degrees Fahrenheit. A two (2) day supply of perishable foods and a seven (7) day supply of non-perishable food were observed. All equipment, appliances, dishes, and utensils are clean and well maintained.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space are operable.

Toxins:
All toxins are locked and stored in a wooden cabinet in the backyard.

Water Temperature:
The water temperature is 105.3 degrees in the resident bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in a locked cabinet which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to clients. The client's medications are stored in a locked cabinet in the hallway.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: STAR HOUSE 5	FACILITY NUMBER: 198320227
	VISIT DATE: 03/01/2022

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Clients & Staff Files:
The applicant is handling the cash resources of the clients. Records of staff and residents are stored in a locked cabinet in the basement.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the client's use all stored in the activity room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pool in the premises..

Fire clearance:
A Fire Clearance inspection was conducted on 12/7/2021 with approval for a capacity of five (5) ambulatory individuals.

Component III:
The applicant has requested for the Regional Office to waive Comp III based on completion of Comp III on this date: 2/23/2016. Component III was waived due to the applicant having licensed facilities of the same category, ARF, by Community Care Licensing Division.

The following items need to be corrected prior to licensure. Proof of corrections shall be submitted to Licensing by 3/11/2022.

§ Water heater must be inaccessible to clients
§ Post a PUB475 poster (20X26)
§ More night lights in the hallway to client bedrooms and common bathrooms
§ Repair a broken dining chair
§ Mount the fire extinguisher in the staff bedroom

An exit interview was conducted, and a copy of this report has been furnished to the Applicant Pamela Broderick.

END OF REPORT

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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