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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320374
Report Date: 08/15/2024
Date Signed: 08/15/2024 03:16:26 PM

Document Has Been Signed on 08/15/2024 03:16 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 4FACILITY NUMBER:
198320374
ADMINISTRATOR/
DIRECTOR:		PALOMINO, LAURAFACILITY TYPE:
735
ADDRESS:1207 KORNBLUM AVENUETELEPHONE:
(310) 908-1504
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 4CENSUS: 3DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Executive Director - Pamela A BroderickTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On 08/15/2024 Licensing Program Analysts (LPAs) Leandro and Enriquez conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Executive Director, Pamela Broderick. LPA explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection.

The facility is licensed to serve 4 ambulatory clients ages 18 through 59 years.

There are 3 ambulatory clients residing in the facility.

The facility is a 1 story house located in a residential street. The home consists of an office, 4 client bedrooms, 1 activity room, 2 bathrooms, 1 attached garage, and a backyard patio area with shaded seating.

Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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 2
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: 08/15/2024
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LPAs toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

LPAs 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. Smoke and carbon monoxide detectors were in compliance and operational. There are several fire extinguishers on the premises, and they were last serviced on 03/2024.

4 out of 4 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 tested hot water temperature and it measured between 106.8 degrees Fahrenheit. This facility provides clients with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

No deficiencies are being cited based on LPAs observation in accordance with the California Code of Regulations, Title 22. An exit interview was conducted and copy of this report was left with the Executive Director.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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