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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320227
Report Date: 04/15/2024
Date Signed: 04/15/2024 02:32:05 PM

Document Has Been Signed on 04/15/2024 02:32 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:STAR HOUSE 5FACILITY NUMBER:
198320227
ADMINISTRATOR/
DIRECTOR:		BRODERICK, PAMELAFACILITY TYPE:
735
ADDRESS:2719 EL DORADO STREETTELEPHONE:
(310) 542-8895
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 4CENSUS: 4DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:49 AM
MET WITH:Administrator Shannon HamlingTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 04/15/2024 at 10:49 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator Shannon Hamling. LPA explained the purpose of the visit and were accompanied by Staff inside and outside the facility during this inspection.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (2) clients' rooms, (1 1/2) 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.

The facility is licensed to operate for (4) ambulatory adults ages 18 - 59. The clients are Harbor Regional Center consumers.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

2 out of 2 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Cloyd tested hot water temperature and it measured 110.4 degrees Fahrenheit. This facility provides clients with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.



Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STAR HOUSE 5
FACILITY NUMBER: 198320227
VISIT DATE: 04/15/2024
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Five (5) staff records were reviewed, 5 out of 5 staff records had current had required criminal record clearances or criminal record exemptions. One staff members were interviewed.

Four (4) client records were reviewed and, 4 out of 4 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. Two client medications were reviewed. LPA Cloyd reviewed P&I money, 4 out of 4 residents P&I were not commingled with facility funds or petty cash.

No deficiencies cited.

An exit interview was conducted, technical assistance provided and a copy of this report was discussed and left with the Administrator Shannon Hamling.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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