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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320227
Report Date: 08/26/2023
Date Signed: 08/26/2023 05:53:35 PM

Document Has Been Signed on 08/26/2023 05:53 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: 4CENSUS: 4DATE:
08/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Laura Palomino TIME COMPLETED:
12:12 PM
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On 08/26/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Laura Palomino. LPA explained the purpose of today’s visit. The facility is licensed to operate for (4) ambulatory adults ages 18 - 59. The clients are Harbor Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (2) clients' rooms, (2) bathrooms, a living area, a dining area, a kitchen, an outside seating area, an activity room, a basement, (1) staff room, (1) staff bathroom, and a garage used for storage .

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.9 degrees F. A comfortable temperature of 75 F. degrees was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were charged. A review of the Medication Administration Record (MAR) was observed to be maintained in order and complete.

(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2023
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: 08/26/2023
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an isolation room in the rear of the home adjacent to the garage.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 04/13/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 01/03/23 through 01/03/24. The facility has a Surety Bond in place that is current.

An audit of clients #1-#4 (C1-C4) service files and staff #1-#6 (S1-S6) personnel files revealed to be complete. An audit of the client's P&I is maintained in order and complete. Interviews were conducted with (4) clients. The facility has the current administrator's certification on file for Laura Palomino #6064973735 - Expiration 01/23/25. The facility is current on licensed fees. The facility is currently using outside staffing agency from Golden Arches.

No deficiencies during this inspection visit.

An exit interview was conducted with Laura Palomino and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2023
LIC809 (FAS) - (06/04)
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