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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320227
Report Date: 01/26/2023
Date Signed: 02/06/2023 02:18:19 PM

Document Has Been Signed on 02/06/2023 02:18 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:STAR HOUSE 5FACILITY NUMBER:
198320227
ADMINISTRATOR:BRODERICK, PAMELAFACILITY TYPE:
735
ADDRESS:2719 EL DORADO STREETTELEPHONE:
(310) 542-8895
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 5CENSUS: 4DATE:
01/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:PAMELA BRODERICKTIME COMPLETED:
11:15 AM
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On 1/26/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an announced case management - decrease in capacity visit at this home. LPA was greeted by Administrator Laura Palomino and Licensee Pamela Broderick and explained the purpose of today’s visit.

The facility was licensed on 4/22/2022 with a capacity of five (5), age range 18 through 59; approved for five (5) ambulatory. The licensee is requesting a decrease in capacity to four (4) ambulatory.

LPA Montoya toured the facility with Administrator Laura Palomino and Licensee Broderick. LPA observed the following:

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; a basement which consists of a bathroom and office/storage.

Bedrooms (Residents):


Two shared (2) bedrooms for ambulatory clients. Both 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.

Bedroom (Other):


The third bedroom is a recreation room for clients and it consists of a table, 4 chairs, a lamp, 2 cabinets with drawers, 2 cabinets with shelves, books, puzzles, building blocks, bingo, chess, and a karaoke machine.

REPORT CONTINUED IN LIC 809C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STAR HOUSE 5
FACILITY NUMBER: 198320227
VISIT DATE: 01/26/2023
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Bedroom (Staff):
The basement is an office space for staff.

Client files:
There are four client (C1-C4) file folders.

LPA advised Licensee Broderick that approval for decrease in capacity is still subject to fire clearance which is pending.

Exit interview conducted and a copy of this report is provided to Licensee Pamela Broderick.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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