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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320374
Report Date: 08/22/2024
Date Signed: 08/22/2024 10:09:30 AM

Document Has Been Signed on 08/22/2024 10:09 AM - 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:
08/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Director of Programs - Clare Mills GreyTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 08/22/2024 at around 8:00 AM Licensing Program Analyst (LPA) Leandro conducted an unannounced continuation visit for the Required – 1 Year Inspection to the above-named facility and met with the Director of Programs, Clare Mills Grey. LPA explained the purpose of the visit.

The Annual Licensing Fees are current.

Facility records were reviewed and the facility had required documentation.
5 staff records were reviewed, 5 out of 5 staff records had required documentation.
3 client records were reviewed and, 3 out of 3 client records had required documentation.

No deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted, and a copy of this report was left with the Director of Programs.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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