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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603625
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:11:46 PM


Document Has Been Signed on 06/21/2024 04:11 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:STELLAR CAREFACILITY NUMBER:
374603625
ADMINISTRATOR:LINDA CHOFACILITY TYPE:
740
ADDRESS:4518 54TH STREETTELEPHONE:
(619) 287-2920
CITY:SAN DIEGOSTATE: CAZIP CODE:
92115
CAPACITY:120CENSUS: 92DATE:
06/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Administrator Brandon ChoTIME COMPLETED:
02:41 PM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Brandon Cho.

Today's visit was in response to a licensee self-submitted report to the CCLD San Diego Regional Office (received on 06/18/2024), involving Resident #1 (R1). [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. According to the incident report R1's xray revealed a fracture in right foot, unknown origin.

During today’s visit, LPA performed a brief facility tour and welfare check on R1, finding no safety concerns. LPA interviewed resident and outside source. LPA also collected copies of and reviewed pertinent records. According to R1’s latest medical x-ray report (dated 6/13/2024) R1 foot showed no acute fracture, chip or dislocations.

Based on the evidence, no deficiencies were cited for the incident. Also, no deficiencies were observed during today’s visit.



An exit interview was conducted with Administrator Cho, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy RodgersTELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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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