198320374-8-2-2023-11-AS-SLEO-CUBR5P-20230802124329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320374
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:43:51 PM

Document Has Been Signed on 08/02/2023 12:43 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 4		FACILITY NUMBER:	198320374
ADMINISTRATOR:	PALOMINO, LAURA		FACILITY TYPE:	735
ADDRESS:	1207 KORNBLUM AVENUE		TELEPHONE:	(310) 908-1504
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY: 4		CENSUS: 0	DATE:	08/02/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Pamela Broderick		TIME COMPLETED:	12:58 PM

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On 08/02/2023 Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Socorro Leandro conducted an announced visit to the facility for purpose of a pre-licensing evaluation. Today’s pre-licensing evaluation was conducted with applicant Pamela Broderick.

On 10/10/2022 an application was submitted to CCLD, for Initial license for an Adult Residential Facility to serve adults age range 18 through 59. The requested capacity is for four (4) clients of which 4 may be non-ambulatory clients. The facility consists of an office, 4 client bedrooms,1 activity room, 2 bathrooms, 1 story house.

LPM and LPA conducted a review of the Physical Plant, Bedrooms, Bathrooms, Supplies, Food Service, Medications, Records, Administration, Activities, Pe-Licensing Checklist and Component III Orientation.

MEDICATIONS

There is a locked centralized storage area for client medications.

PHYSICAL PLANT

Facility is clean, sanitary, and in good repair. Protective devices are in place to include nonskid material on rugs. Indoor and outdoor passageways, inclines, ramps, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68 degrees and 85 degrees. Ramps, open porches, and areas of potential hazard are well-lit and equipped with sturdy hand railings.

BEDROOMS

Client bedrooms are large enough to allow for easy passage and to accommodate furniture and assistive devices such as wheelchairs, walkers, or oxygen equipment. No client bedroom is a passageway to another room, bath or toilet.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STAR HOUSE 4	FACILITY NUMBER: 198320374
	VISIT DATE: 08/02/2023

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There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is a dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) night stand per two (2) clients.

BATHROOMS

There is at least one (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (1) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is between 105-120 degrees Fahrenheit. Bathroom is located near client bedrooms. There are night-lights in the hallways outside non-private bathrooms.

SUPPLIES

There are client personal hygiene supplies to include feminine napkins, soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths.

FOOD SERVICE

Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0 degrees Fahrenheit. Refrigerator is a maximum of 45 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS

There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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 4	FACILITY NUMBER: 198320374
	VISIT DATE: 08/02/2023

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ADMINISTRATION

The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

ACTIVITIES

There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors.

MISCELLANEOUS

There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is a designated laundry space. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. Vehicles used to transport clients are in safe operating condition.

PRE-LICENSING CHECKLIST

Completed by licensee and reviewed by LPM & LPA.

COMPONENT III orientation was conducted with the applicant

During the pre licensing inspection no items were observed which do not comply with applicable laws and regulations.

An exit interview was conducted, and a hard copy of this report has been furnished to the applicant.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to the applicant.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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