<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601043
Report Date: 10/20/2021
Date Signed: 10/20/2021 07:37:34 PM

Document Has Been Signed on 10/20/2021 07:37 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:STAR HOUSE 1FACILITY NUMBER:
198601043
ADMINISTRATOR:BRODERICK, PAMELAFACILITY TYPE:
735
ADDRESS:22410 EVALYN AVENUETELEPHONE:
(310) 378-3524
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 6CENSUS: 5DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Darren Autrey/Maria NunezTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/20/2021, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with caregiver Darren Autrey and later joined by acting Administrator Maria Nunez and explained the purpose of today’s visit. The facility is licensed to operate for six (6) developmentally disabled ambulatory clients between the ages of 18 through 59.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) client rooms, one (1) staff room/office with a bathroom, two (2) bathrooms, one (1) living areas, one (1) dining area, kitchen, and outside patio area with a table and an umbrella for shade. The garage is attached and includes an additional refrigerator/freezer and exercise equipment for the clients.

LPA and caregiver Darren Autrey toured the physical plant and was later joined by acting Administrator Maria Nunez. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 112.8 F to 116.6 F in the bathrooms and kitchen sink. A comfortable temperature of 74 degrees was maintained in the facility.


Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STAR HOUSE 1
FACILITY NUMBER: 198601043
VISIT DATE: 10/20/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Evaluation Report Continues on LIC 809-C

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. There are three (3) fire extinguishers fully charge, one (1) in the kitchen one (1) in the laundry room and one (1) in the garage. Smoke detectors and carbon monoxide were operable. A reviewed of Medication Records Administration (MAR) and observed to be maintained in order and accurate.


During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.



No deficiencies were cited during this inspection visit.

Advisory Notes – Two (2) Technical Assistance were issued, please see LIC9102-AN.

An exit interview was conducted and a copy of this report was provided to acting Administrator Maria Nunez.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4