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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005706
Report Date: 02/19/2025
Date Signed: 02/19/2025 10:14:50 AM

Document Has Been Signed on 02/19/2025 10:14 AM - 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/
DIRECTOR:		TUMBOKON, LOMMELFACILITY TYPE:
738
ADDRESS:2 MARK LANETELEPHONE:
(916) 651-8235
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 5CENSUS: 2DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Lommel TumbokonTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 5 clients of which 3 can be non-ambulatory. The facility currently has 2 clients. Administrator (AD) Lommel Tumbokon was present to conduct facility tour.

LPA along with AD toured the facility at 8:25 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The facility consists of 5 client bedrooms, a living room/dining room area, exercise room, sensory room, medication room, and kitchen as well as 3 bathrooms. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 111.9 degrees F and 116.7 degrees F in all bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alerts were operational during today's visit. LPA toured the kitchen and observed sharps locked in a box during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts monthly emergency drills with the last drill conducted on 1/7/2025. Outside grounds were toured. Walkways around the facility were clear of hazards. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise and sensory therapy. There is shaded outdoor seating for clients. LPA observed the emergency food and water supply. LPA reviewed two client electronic files and four staff files. All electronic client files contained the required information including needs and services plans and physician reports. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. CONTINUED ON FORM LIC809-C DATED 2/19/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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: 02/19/2025
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LPA reviewed medication storage and administration. Medications are stored in a locked medication cart in the medication room. Medications are being administered per physician order.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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