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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005706
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:46:23 PM

Document Has Been Signed on 02/25/2022 12:46 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SOUTH STAR #2FACILITY NUMBER:
306005706
ADMINISTRATOR:TUMBOKON, LOMMELFACILITY TYPE:
738
ADDRESS:2 MARK LANETELEPHONE:
(916) 869-8834
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 5CENSUS: 0DATE:
02/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kim Hamilton-Royse, Program Director and Lommel Tumnokon, Administrator TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Kathrina Chin made an announced visit to the facility for the purpose of conducting a pre-Licensing inspection. LPA met with and was granted entry by Administrator, Lommel Tumnokon and Program Director, Kim Hamilton-Royse. This is a newly build facility. The facility is a Community Crisis Home-ARF.

On February 3, 2022, a fire clearance was granted for three (3) non-ambulatory clients and two (2) ambulatory clients. The facility is a one story structure with five bedrooms and three bathrooms. There is a three car garage. Rooms are provided with adequate furniture, appropriate linens and adequate storage space. Hallways are kept free from any obstruction or tripping hazard. Bathrooms have fixtures and in good repair. Hot water temperature is tested and is within regulatory requirements. Smoke detectors and Carbon Monoxide alarms were tested and observed to be operational. Fire extinguishers were mounted and charged. Kitchen are clean. Applicant understands that facility will meet the minimum 2 day perishable and 7 day non-perishable food stocked requirements. Posting requirements were in place. Common areas were provided with adequate furniture and in good repair. Medications, records, sharp items and toxic or cleaning supplies will be made inaccessible to clients. There are three first aid kits. There is a outdoor covered patio with outdoor furniture. No clients were in care during this visit.

A Component III was completed with Applicants. LPA reviewed Personnel Policies, Fingerprinting, Abuse Reporting Procedures, In-Service Training and Medication Procedures.

The Pre-Licensing evaluation has been completed. It appears this facility meets the requirements for licensure. The license will be granted upon completion of a final review and approval from the Application Specialist. An exit interview was conducted with Kim Hamilton, Program Director and Lommel Tumnokon, Administrator. Copy of this report will be provided to Kim Hamilton-Royse.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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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