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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320227
Report Date: 07/10/2025
Date Signed: 07/15/2025 04:54:18 PM

Document Has Been Signed on 07/15/2025 04:54 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:
07/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Clare Mills-GreyTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 07/10/20225 at 1:45 PM, Licensing Program Analyst (LPA) Wendy Gibbs conducted an unannounced Annual Visit to the facility listed above. LPA met with Programs Director, Clare Mills-Grey, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve four (4) ambulatory adults ages 18-59.
Physical Plant/Structure 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. LPA observed all walkways around the outside of the facility were clean, clear, free of debris, hazards, and obstructions. LPA observed a shaded patio in the back with a table and chairs available for resident use. LPA did not observe any bodies of water on the premises. There are no security bars or weapons on the premises.
Bedrooms LPA inspected the client bedrooms and observed the walls and floors were clean and in good repair. The bedrooms have the required furniture including beds, dressers, nightstands, and ample storage space for client’s personal belongings. LPA observed the mattresses are in good repair. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed bedrooms have ample lighting.
Bathroom LPA observed bathrooms met Title 22 regulations and are operable. LPA observed the shower to be clean and free of mold and mildew. LPA observed storage areas for personal hygiene. LPA observed an ample supply of towels, in good repair, and an additional supply of personal hygiene products available for clients. The water temperature measured 107.1-degrees Fahrenheit in both bathrooms.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STAR HOUSE 5
FACILITY NUMBER: 198320227
VISIT DATE: 07/10/2025
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Kitchen LPA observed the kitchen to be clean and sanitary. LPA observed all appliances are operable. LPA observed an ample supply of cookware, dishware, and cutlery in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of non-perishable foods. LPA observed cleaning supplies secured in the locked cabinet under the kitchen sink and are inaccessible to clients. LPA observed sharps secured in a locked cabinet and drawer in the kitchen and are inaccessible to clients. The water temperature measured 106.9-degrees Fahrenheit.
Common Areas LPA observed in the living room are two (2) large couches and two chairs. LPA observed an activity room with an ample supply of games, arts, craft, movies, and activities available for client use. The activity room has a table and chairs to accommodate clients. LPA observed the dining room has a large dining table and chairs to accommodate all clients. LPA observed all walkways and hallways in the facility are clean, clear and free of hazards and obstructions. All rooms were observed with ample lighting. The facility was maintained at a comfortable temperature.
Medications LPA observed Centrally Stored Medication secured in a locked cabinet in the hall and are inaccessible to clients. LPA observed medications are in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for four (4) clients and observed four (4) out of four (4) client’s medications are consistent with properly documented records.
File Review LPA reviewed the files for four (4) clients. LPA observed four (4) out of four (4) client binders have the required documents. LPA reviewed four (4) clients P&I and observed four (4) out of four (4) clients P&I are consist with properly documented records and receipts. LPA reviewed five (5) staff files and observed five (5) out of five (5) staff files have the required documents, certifications, training, and clearance. LPA observed the Administrators, Administrator Certificate is valid till 12/03/2026. During the record review, LPA observed the facility’s Licensing Fees are current. LPA reviewed the facility’s Surety Bond through Liberty Mutal that is valid till 07/02/2026. LPA reviewed the facility’s Liability Insurance through Acord that is valid till 01/03/2026.
Safety LPA observed smoke and carbon monoxide detectors are operable and in good repair. LPA observed the Emergency and Disaster Plan for Adult Community Care Facility that was last updated on 02/24/2025. The last Emergency Drill was conducted on 04/30/2025. The last Fire Prevention Inspection was conducted by the Torrance Fire Department on 02/04/2025. LPA observed five fully charged fire extinguishers last serviced on 10/15/2024. LPA inspected the First Aid Kit and observed it has the required items and a current manual. The facility has a working landline telephone. LPA observed all required postings posted throughout the facility.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STAR HOUSE 5
FACILITY NUMBER: 198320227
VISIT DATE: 07/10/2025
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Infection Control Upon entry is a sanitizing station that consists of a sign-in log, hand sanitizer, masks, thermometer, and gloves available. LPA observed infection control signs posted throughout the facility. LPA observed a 90-day supply of Personal Protective Equipment.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Program Director, Clare Mills-Grey, and Administrator, Ashley Crutchfield, and a copy of this report was provided

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4