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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602198
Report Date: 05/02/2024
Date Signed: 05/02/2024 04:06:16 PM

Document Has Been Signed on 05/02/2024 04:06 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:STAR HOUSE IIIFACILITY NUMBER:
198602198
ADMINISTRATOR/
DIRECTOR:		BRODERICK, PAMELAFACILITY TYPE:
735
ADDRESS:5020 MACAFEE ROADTELEPHONE:
(310) 542-8895
CITY:TORRANCESTATE: CAZIP CODE:
90505
CAPACITY: 5CENSUS: 5DATE:
05/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Shanon HamlingTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 05/02/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced case management visit to the facility listed above for an incident reported to Community Care Licensing (CCL). During today’s visit LPA met with Administrator, Shannon Hamling, and the purpose of today’s visit was explained. There are five (5) clients residing in the facility and three (3) were present during today’s visit.
CCL received a special incident report (SIR) on 05/01/24 stating on the morning of 04/29/24, Staff S2 and S3 entered the room of C1 and observed Staff S1, a 1 on 1 caregiver, shirtless and asleep in Client C1’s bed with C1 in it.
During today’s visit, LPA toured the facility, interviewed Staff (S2 - S4), interviewed Client (C1) with conservator, interviewed C1’s conservator, and received documents pertinent to the incident. The documents include C1’s Physician Report, Needs and Service Plan, Harbor Regional Center Individual Person-Centered Plan, Harbor Regional Center Quarterly Progress Report, and Staff S1 Personnel File.

During today's visit no deficiencies were observed or cited.

An exit interview was conducted with Licensee, Pamela Broderick, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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