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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602198
Report Date: 11/04/2021
Date Signed: 11/19/2021 02:40:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/28/2021 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20211028092846
FACILITY NAME:STAR HOUSE IIIFACILITY NUMBER:
198602198
ADMINISTRATOR:BRODERICK, PAMELAFACILITY TYPE:
735
ADDRESS:5020 MACAFEE ROADTELEPHONE:
(310) 542-8895
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY:5CENSUS: 5DATE:
11/04/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Rachael TuazonTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident has access to hazardous items
INVESTIGATION FINDINGS:
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On 11/04/2021 around 09:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Suzy Nunez.

The Investigation consisted of the following: On 11/04/2021 LPA Calderon interviewed Administrator Suzy Nunez(S1) and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, duty and maintenance list for staff. On 11/04/2021 LPA Calderon interviewed caregiver (S2-S4). On 11/04/2021 LPA Calderon called witness and left 3 message for interview. On 11/04/2021 LPA Calderon attempted to interview resident (R1-R5) but all could not answer questions due to mental challenges.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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 3
Control Number 11-AS-20211028092846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III
FACILITY NUMBER: 198602198
VISIT DATE: 11/04/2021
NARRATIVE
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Allegation: Resident has access to hazardous items

On 11/04/2021 LPA Calderon interviewed S1 who states that staff are trained to wash dishes and to put knifes away but does not denied that a butter knife was left out on top of the counter. On 11/04/2021 LPA Calderon reviewed staff and resident rosters. On 11/04/2021 LPA Calderon interviewed S1-S4 and all staff state that they are trained to lock up any object that can hurt residents, On 11/04/2021 LPA Calderon reviewed video which shows a butter knife and dishes left on the counter. On 11/04/2021 LPA Calderon toured the facility with administrator S1 to include the kitchen area, LPA Calderon did not see any knifes left on the counter, but did find violations of title 22 regarding unlocked drawers where knifes are kept and unlocked drawers where chemicals are kept under the sink. Staff did not know how to lock the drawers and state that they have been broken for some time.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 are being cited on the attached

A exit interview was conducted with Administrator Suzy Nunez, and a hard copy was provided by hand for records
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20211028092846
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III
FACILITY NUMBER: 198602198
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2021
Section Cited
CCR
80087(G)(1)
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80087 Buildings and Grounds:(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger...(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.This requirement is not met as evidenced by:


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Administrator will replace locks to cabinet drawer for knives and cabinet draws under sink and will also do formal training for all staff to advise management if there are any issues.
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Based on interviews, video and inspection of kitchen area the allegation of hazardous material poses a health & Safety risk to residents in care.
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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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3