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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005706
Report Date: 08/18/2022
Date Signed: 08/18/2022 04:20:18 PM

Document Has Been Signed on 08/18/2022 04:20 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:
(714) 760-4603
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 5CENSUS: 1DATE:
08/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Oscar Mejia - House Administrator
Lommel Tumbokon - Administrator		TIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to South Star #2. LPA Velazquez was allowed entry into the facility and met with House Administrator (HA) Oscar Mejia. Administrator Lommel Tumbokon arrived later to assist with the visit. The purpose of the visit was to conduct a Post Licensing visit. The facility is a Community Crisis Home - Adult Residential Facility. The facility is licensed for 5 ambulatory clients of which 3 may be non-ambulatory. The facility has also been approved for delayed egress. The last emergency disaster drill was conducted on July 16, 2022.

At 2: 56 PM LPA Velazquez conducted a tour of the physical plant along with HA Mejia The 1 story home consists of 5 client bedrooms with 3 bathrooms. There is sensory room, living room, sitting area, activity room, living room, medication room, dining area and kitchen. The 1 client in the facility appeared well-groomed and well cared-for. The client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, showers were free of mold/mildew and a non-skid surface or mat was in place. Client bath towels and personal hygiene supplies were adequately stocked. LPA Velazquez tested the hot water temperature in the client bathrooms and the temperature measured at 109.5 degrees Fahrenheit in the first bathroom, at 112.6 degrees Fahrenheit in the second bathroom, and at 105.5 degrees Fahrenheit in the third bathroom which HA Mejia verified.

LPA Velazquez inspected the kitchen along with HA Mejia. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were interconnected, tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to clients. The home has a fire sprinkler system that has been approved by the Fire Marshal.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 306005706
VISIT DATE: 08/18/2022
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LPA Velazquez along with HA Mejia toured the outside grounds. There were no bodies of water present. There were two concrete patio areas with shading and sufficient seating for clients. Walkways around the home were clear of hazards. There were no security bars or weapons on the premises.

LPA Velazquez conducted a review of one client file. No staff files were reviewed at the time of this visit. The Client medications and Medication Administration Records were reviewed and found to be in order. The First Aid kit and manual were checked and found to be in order.



There were no deficiencies issued during this Post Licensing visit. An exit interview was conducted with House Administrator Oscar Mejia and Administrator Lommel Tumbokon and a copy of this report along was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
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