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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601043
Report Date: 10/29/2023
Date Signed: 10/29/2023 03:51:23 PM

Document Has Been Signed on 10/29/2023 03:51 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 6DATE:
10/29/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:BRYAN BENTLEYTIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/29/23, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with DSP Laura Romero and explained the purpose of today’s visit. Staff Bryan Bentley arrived later and joined the visit.

There are currently (6) Regional Center consumers in placement. All (6) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 6 bedrooms, 3 bathrooms, family room/office, living room, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room and attached garage.

At around 9: 30 AM, LPA Montoya and Staff Bentley toured the physical plant. 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 was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The bathrooms were found to be within Title 22 regulations and were clean and operational. At around 9:55 AM, LPA Montoya and Staff Bentley checked the water temperature in the client bathrooms, and it was measured at 126.5 degree F. and 125.8 degree F. A comfortable temperature was maintained in the facility.

LPA Montoya 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 residents. The kitchen was inspected and there is a sufficient perishable and non-perishable food supply. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was complete and accurate. The facility conducted a disaster drill on 09/25/23. A working landline telephone (310) 378-3524 was observed.

Evaluation Report Continues LIC 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2023
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: STAR HOUSE 1
FACILITY NUMBER: 198601043
VISIT DATE: 10/29/2023
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The facility is current on Community Care Licensing annual dues.

An audit of six out of six client service files (R1-R6) and four staff files (S1-S4) was conducted. Interviews were conducted with three out of six clients and one member of staff.

LPA Montoya observed the following deficiencies:

1. The water temperature in the bathrooms used by clients were measured at 126.5 degree F. and 125.8 degree F.
2. LPA Montoya did not observe client's (C4) medical assessment that includes the result of an examination for communicable tuberculosis and other contagious/infectious diseases.
3. No health screening record of S3 on file.

A technical assistance was given to Staff Bentley.

Deficiencies are being cited based on LPA observations, interviews conducted and records review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with Staff Byran Bentley.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/29/2023 03:51 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 10/29/2023 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: STAR HOUSE 1
FACILITY NUMBER: 198601043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. The water temperature in the bathrooms used by clients were measured at 126.5 degree F. and 125.8 degree F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Staff Bentley shall adjust the water temperature to comply to this section of Title 22 as stated above. Bentley agreed to record the water temperature every two hours for the next twenty four hours and shall submit the record to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 10/30/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/29/2023 03:51 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 10/29/2023 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: STAR HOUSE 1
FACILITY NUMBER: 198601043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA Montoya did not observe client's (C4) medical assessment that includes the result of an examination for communicable tuberculosis and other contagious/infectious diseases. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Staff Bentley shall obtain a medical assessment for client #4 and comply to the Section above. POC shall be submitted to CCLD via email to lourdes.montoya@dss.a.gov by the POC due date 11/17/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/29/2023 03:51 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 10/29/2023 at 03:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: STAR HOUSE 1
FACILITY NUMBER: 198601043

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA Montoya did not observe a health screening record for one Staff (S3). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2023
Plan of Correction
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Staff Bentley agreed to maintain a health screening record for S3 on file. A copy of S3's health screening shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 11/17/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2023


LIC809 (FAS) - (06/04)
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