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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602198
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:30:00 PM

Document Has Been Signed on 06/20/2024 04:30 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:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:29 PM
MET WITH:Administrator Shannon HamlingTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 06/20/2024 at 1:29 PM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator Shannon Hamling. LPA explained the purpose of the visit and was accompanied by Staff inside and outside the facility during this inspection.

The facility is licensed to operate for (5) non-ambulatory adults of which (5) may be bedridden ages 18 - 59. Currently, the facility has (1) hospice client in care and (3) clients over 59 years old. The facility is approved for (2) hospice clients and (2) out of (3) clients have age exceptions. The clients are Harbor Regional Center consumers. Annual Fees are current.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (5) clients' rooms, (2) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage used for storage.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

5 out of 5 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. LPA Cloyd tested hot water temperature and it measured 116.4 degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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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Document Has Been Signed on 06/20/2024 04:30 PM - It Cannot Be Edited


Created By: Regina Cloyd On 06/20/2024 at 04:02 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STAR HOUSE III
FACILITY NUMBER: 198602198

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(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: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for two out of five staff personnel which poses a potential health risk to persons in care. LPA Cloyd did not observe TB exam results for Staff #2 (S2) and Staff #5 (S5).
POC Due Date: 07/08/2024
Plan of Correction
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The Administrator will email S2 and S5's TB exam results to regina.cloyd@dss.ca.gov by the POC due date. The Licensee will ensure that all personnel staff have TB exams on file.
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STAR HOUSE III
FACILITY NUMBER: 198602198
VISIT DATE: 06/20/2024
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LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

Five (5) staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions.

Five (5) client records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. Two client medications were reviewed. LPA Cloyd reviewed P&I money, 5 out of 5 residents P&I were intack and not commingled with facility funds or petty cash.

Deficiencies are being cited based on LPA's record review in accordance with the California Code of Regulations, Title 22, see LIC809D. LPA did not observe TB exam results for Staff #2 and Staff #5 which poses a potential health risk to clients in care.

An exit interview was conducted, technical assistance provided, plan of correction developed, and a copy of this report and appeals was discussed and left with the Administrator Shannon Hamling.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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