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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801434
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:21:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/20/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20231020082513
FACILITY NAME:STARSHIPFACILITY NUMBER:
565801434
ADMINISTRATOR:JORDAN WARDFACILITY TYPE:
772
ADDRESS:1760 SOUTH LEWIS ROADTELEPHONE:
(805) 383-3669
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:15CENSUS: 15DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Ayana ChurnTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff did not ensure clients in care were properly supervised
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 11:35AM and met with Program Director Ayana Churn. Entrance interview conducted.

During today's visit, LPA interviewed Program Director at 11:37AM, conducted staff and resident interviews from 12:40PM to 02:38PM. LPA toured the facility during the visit and the LPA obtained staffing schedules. The following was then determined:

The complaint alleges that during the NOC shift on at least two (2) occasions, there was only one (1) staff scheduled for both this facility and another facility on the same campus. Interviews revealed that the facility is short-staffed, with many open positions they are actively recruiting and attempting to hire for. Additionally, staff indicated there are call outs and on call staff aren't always available to cover unplanned vacant shifts.
Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20231020082513
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: STARSHIP
FACILITY NUMBER: 565801434
VISIT DATE: 10/25/2023
NARRATIVE
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Interviews revealed that there have been at least two (2) times that Staff #1 (S1) has worked alone during the overnight shift and had to leave this facility to go to the other facility to go check on the clients residing there, as S1 was the only staff present to oversee both facilities. There are fifteen (15) clients in each of the two (2) facilities and although they are on the same campus, they have separate addresses and are located in separate buildings. Staff schedule reviewed revealed that there are many open shifts indicated and on October 8, there were no staff scheduled for this facility during the NOC shift. S1 was scheduled at another facility during the PM shift and reportedly stayed by themselves to cover at both facilities. Therefore, based on interview and staff schedule review, there is sufficient evidence to support the allegation and the allegation "Staff did not ensure clients in care were properly supervised" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9009-D). Exit interview conducted with Program Director Ayana Churn. Today’s reports and appeal rights were reviewed and provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20231020082513
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARSHIP
FACILITY NUMBER: 565801434
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
CCR
81065(a)
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81065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
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Program Director indicated all shifts are currently covered. Program Director will provide CCL with a plan to ensure sufficient staffing going forward, including steps to take to minimize calls outs and what the plan is if staff call out, Plan will be sent to CCL by POC due date.
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Based on interview and staff schedule review, the facility did not comply with the above cited section, as on 10/08/2023, there were no staff scheduled during the NOC shift, so S1 stayed to cover both this facility and another facility, leaving 15 clients without any supervision during the shift.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3