<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604408
Report Date: 09/24/2021
Date Signed: 09/24/2021 07:41:21 PM

Document Has Been Signed on 09/24/2021 07:41 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:STARGAZER HOME CARE INC.FACILITY NUMBER:
374604408
ADMINISTRATOR:KHADIRI, ROWENAFACILITY TYPE:
735
ADDRESS:7574 ANGETON DRIVETELEPHONE:
(858) 695-9431
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 4CENSUS: 0DATE:
09/24/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Applicant, Rowena KhadiriTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Natasha Persaud conducted an announced Pre-Licensing/Component III inspection. LPA identified herself and explained the purpose of the visit with Applicant/Licensee, Rowena Khadiri to ensure Title 22 compliance. An initial application was received by the Department on 12/17/2020. The Applicant/Licensee requested to be licensed for a capacity of four (4) Ambulatory Developmentally Disabled adults, ages 18-59.

Structure- The facility is a one story structure with 3 bedrooms, and 2 bathrooms. There is an outdoor covered area for client use. No bodies of water were observed. Per the Applicant, there are no firearms or weapons on the premises.
Bedrooms Residents- Rooms #1, #2, and #3 will be used for Ambulatory clients only.
Bedrooms Staff- There are no staff rooms.
Bathrooms- All bathrooms have a working toilet, sink, and non-skid rugs.
Linens & Hygiene Supplies- Adequate supply.
Emergency Phone Numbers, Exit Plan and Required Postings- Posted.
Smoke Detectors and Carbon Monoxide Detectors- Operational.
Appliances- Stove burners, oven, microwave, washer, and dryer working.
Toxins- Stored in a locked garage.
Water Temperature- Measured at 120 degrees F.
Medications- Centrally stored and locked in a closet.
First-Aid Kit- Stored in a locked closet.
Resident & Staff Files- Located in a locked closet.
Activities- Adequate supplies.
Fire clearance- Approved on 05/26/2021.
Component III- Conducted at the Pre-Licensing visit. Information provided about how to operate the facility within substantial compliance.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: STARGAZER HOME CARE INC.
FACILITY NUMBER: 374604408
VISIT DATE: 09/24/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
All items reviewed during the visit are in compliance. Facility appears to be ready for licensure pending final review. Pre-Licensing is complete and this facility has no deficiencies.

An exit interview was conducted with, Rowena Khadiri Applicant/Licensee, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Applicant/Licensee via electronic mail. An electronic read receipt confirmation was requested to be sent by the Applicant/Licensee upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2