198601043-7-9-2025-11-AS-EMAZ-DK4TH2-20250731144402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601043
Report Date: 07/09/2025
Date Signed: 07/09/2025 05:10:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20250701152704

FACILITY NAME:	STAR HOUSE 1		FACILITY NUMBER:	198601043
ADMINISTRATOR:	BRODERICK, PAMELA		FACILITY TYPE:	735
ADDRESS:	22410 EVALYN AVENUE		TELEPHONE:	(310) 378-3524
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	6	CENSUS: 5	DATE:	07/09/2025
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Clare Mills-Grey		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not assess resident for higher level of care
Staff are mismanaging residents medication
Staff inappropriately relocated a resident
Staff falsified staff documents
Staff did not ensure the facility has food

INVESTIGATION FINDINGS:

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On 07/09/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Director of Programs, Clare Mills-Grey, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

The investigation consisted of the following:
During today's visit, LPA toured the facility, interviewed Staff S1-S4, interviewed Clients C1-C6, conducted a medication audit, and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report, Physician Orders, Medication Administration Record (MAR), client Individual Person-Centered Plan, 2025 Annual Progress Report, Admission Agreement, Incident Reports, Training Logs, In-Service Logs, Weekly Menus, and Grocery Receipts.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 11-AS-20250701152704

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 1	FACILITY NUMBER: 198601043
	VISIT DATE: 07/09/2025

NARRATIVE

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Allegation: Staff inappropriately relocated a resident
The allegation alleges a Client was relocated to another facility without the proper paperwork.
During record review, LPA received and reviewed Client C1’s Admission Agreement dated 06/15/2025 for the facility they were transferred to. The Admission Agreement is signed by Client C1, C1’s conservator, Trust Management Services, the Licensee, and Regional Center Representative. LPA received and reviewed Client C1’s 2025 Annual Progress Report dated 04/30/2025, that states as C1 “gets older and transitions into a more sedentary lifestyle, it is getting harder for C1 to keep up with the other roommates.” Additionally, it states “discussions have started to explore and consider a more suitable environment to ensure C1 continues to have the support C1 will need in the future.” LPA received and reviewed Client C1’ Individual Person-Centered Plan dated 06/20/2024 that indicates C1 may need some prompting and directions while grooming, showering and completing tasks.
During interviews with Staff S1-S4, were asked if any clients were recently transferred to another facility due to requiring a higher level of care, four (4) out of four (4) stated yes, Client C1 recently transitioned to another home due to requiring a higher level of care. Additionally, staff S1-S4, were asked what the process was prior to C1 moving, four (4) out of four (4) stated there was an assessment, medical appointments, meetings with the conservator, and regional center before the decision was made.
LPA contacted Client C1’s service coordinator from Harbor Regional Center, who stated there were meetings, assessments, and discussions with the facility, regional center, and C1’s family regarding C1 being transferred to a facility that can provide a higher level of care.
During an interview with Client C1, was asked how they like the new facility they are residing in, C1 stated they like it. Additionally, C1 was asked if they chose to move there, they stated yes, they went there because they like it.

Allegation: Staff falsified staff documents

The allegation alleges that staff are asked to sign documents indicating they have received training when they have not.
During the facility tour, LPA observed posted on the board is the Star House #1 Training Schedule for Year: 2025. The topics and the months the training will be provided was listed.
During record review, LPA received and reviewed training logs for staff for in-services conducted for 2025. The following are in-services that were provided to the staff: Home and Community Based Services on
01/04/2025 and 01/10/2025, Health Insurance Portability and Accountability Act (HIPPA) on 01/04/2025, A Thorough Understanding of the 7 Rights of Medication Administration on 01/28/2025, Medication

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20250701152704

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 1	FACILITY NUMBER: 198601043
	VISIT DATE: 07/09/2025

NARRATIVE

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Allegation: Staff did not assess resident for higher level of care
The allegation alleges a Client has been showing signs of dementia and did not have them assessed because they didn’t want the Client to move out of the facility.

During record review, LPA reviewed Client C1’s medical and dental appointments attended. Additionally, LPA received and reviewed Client C1 Physician’s Report dated 10/30/2024 that has no indication of Mild Cognitive Impairment or Dementia. LPA received and reviewed Client C1’s 2025 Annual Progress Report dated 04/30/2025 that states as C1 “gets older and transitions into a more sedentary lifestyle, it is getting harder for C1 to keep up with the other roommates.” Additionally, it states “discussions have started to explore and consider a more suitable environment to ensure C1 continues to have the support C1 will need in the future.” LPA received and reviewed Client C1’ Individual Person-Centered Plan dated 06/20/2024 that indicates C1 may need some prompting and directions while grooming, showering and completing tasks.

During interviews with Staff S1-S4, were asked if they observe a change of condition in a Client are they assessed, four (4) out of four (4) stated yes, they are assessed for any change of condition whether medical, behavioral, or socially.
LPA contacted Client C1’s service coordinator from Harbor Regional Center, who stated there were meetings, assessments, and discussions regarding Client C1’s change of condition and needing a higher level of care.
During interviews with Clients C1-C6, were asked if they receive medical treatment when needed, six (6) out of six (6) stated they see a doctor, dentist, and other professionals when needed.

Allegation: Staff are mismanaging residents’ medication

The allegation alleges medications are missing and clients are not getting their medications.

During record review, LPA reviewed the Client’s C2-C6’s Physician Orders, Centrally Stored Medications, and MAR. All medications listed on the Physician Orders were observed in the Clients medication boxes in a secured cabinet in the staff office.

During the facility visit, LPA reviewed the MAR and medications for 5 clients. LPA observed five (5) out of five (5) client’s MARs and medications are consistent with properly documented records.
During interviews with Staff S1-S4, were asked if there was a time clients did not get their medications, four (4) out of four (4) stated there have been no missed medications
During interviews with Clients C1-C6, were asked if they receive their medications, six (6) out of six (6) stated yes they receive their medications.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20250701152704

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 1	FACILITY NUMBER: 198601043
	VISIT DATE: 07/09/2025

NARRATIVE

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Management in January 2025, Bloodborne Pathogens in February 2025, Deaf/Blind Training - DDS on 03/26/2025, Universal Precautions Training in March 2025, Aging, Down Syndrome and Dementia on 03/26/2025, Resident Rights in April 2025, Best Practices When Assisting an Individual with Self-Administration of Medication on 05/25/2025, and Food Prep and Storage on 06/27/2025.
During interviews with Staff S1-S4, were asked if there was a time they were asked to sign that they received training but did not, four (4) out of four (4) stated they have not signed training logs for training they have not received. Staff S1-S4 were asked if they signed training logs that were back dated, four (4) out of four (4) stated no, staff have not signed back dated training logs.
During interviews with Clients C1-C6, were asked if they have any concerns regarding staff training, six (6) out of six (6) stated they have no concerns regarding staff training.
Allegation: Staff did not ensure the facility has food
The allegation alleges that there is no food in the cabinets.
During the facility tour, LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods.
During record review, LPA received and reviewed the four (4) weekly menus posted in the kitchen. LPA observed Clients are provided with three (3) meals a day and snacks. Additionally, LPA received and reviewed weekly grocery receipts from 02/05/2025 to 07/08/2025.
During interviews with Staff S1-S4, were asked what food clients are provided throughout the day, four (4) out of four (4) stated clients are provided with 3 meals a day and three snacks. Additionally, Staff S1-S4 were asked if clients are hungry is there food available, four (4) out of four (4) stated food and snacks are always available for clients.
During interviews with Clients C1-C6, were asked if they receive meals and snacks throughout the day, six (6) out of six (6) stated they receive three (3) meals a day and snacks. Additionally, Clients C1-C6, were asked if they have access to food anytime of the day, six (6) out of six (6) stated they can eat anytime they want, they just ask and staff get them food when they are hungry.

During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated.

LPA did not observe or cite any deficiencies.
An exit interview was conducted with Director of Programs, Clare Mills-Grey, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

LIC9099 (FAS) - (06/04)

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