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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005706
Report Date: 03/15/2024
Date Signed: 03/15/2024 01:43:01 PM

Document Has Been Signed on 03/15/2024 01:43 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
ORANGE COUNTY RO, 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) 852-3665
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 5CENSUS: 3DATE:
03/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lommel Tumbokon, AdministratorTIME COMPLETED:
01:50 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit. Administrator Lommel Tumbokon was also present to assist with the visit.

During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-level home with five client bedrooms, three bathrooms, a large kitchen/living/dining common area, an activity room and a medication room. There are two patios accessible from both wings of the house.

There are currently three clients in care at the facility. All client bedrooms have the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded sitting area and additional umbrellas for the central courtyard and the route of egress is free of clutter and obstructions.

Bathrooms faucets and toilets were operational. Water temperature is noted to be in the appropriate temperature range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted.

Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Emergency food and water supply are observed to be stored in the garage. Facility is replenishing its grocery stock on Saturdays as observed on the weekly schedule.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SOUTH STAR #2
FACILITY NUMBER: 306005706
VISIT DATE: 03/15/2024
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CONTINUED FROM FORM LIC809

Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with up-to-date maintenance. Sharps were observed to be stored in a lockbox located in a kitchen drawer. LPA observed cleaning supplies to be stored in a locked cabinet in the staff area/garage. The medication central storage room was observed to be locked, in addition to the medication being stored in a cart that was verified to be locked. The facility uses an electronic Medication Administration Records solution. LPA reviewed the medication on hand and found no discrepancy in administered quantities or prescription orders.

LPA reviewed three client files and five staff files before conducting five staff interviews and one client interview. Two other clients could not be interviewed as they had left the facility on an outing with staff.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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