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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801434
Report Date: 09/09/2025
Date Signed: 09/09/2025 11:00:03 AM

Unsubstantiated


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
03/11/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20250311091706
FACILITY NAME:STARSHIPFACILITY NUMBER:
565801434
ADMINISTRATOR:MCKIAN NIELSENFACILITY TYPE:
772
ADDRESS:1760 SOUTH LEWIS ROADTELEPHONE:
(805) 383-3669
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:15CENSUS: 15DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Lisa OviedoTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff mishandling residents medication.
Staff not administering residents medication as prescribed.
Staff did not properly store medication.
Staff is not adequately trained.
Staff does not provide scheduled activities for residents.
Staff not keeping hallway free of obstruction.
Insufficient staffing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 03/17/2025 by LPAs M. Arroyo and V. Conway, and a subsequent visit was conducted on 07/09/2025 by LPA M. Arroyo. On today’s visit, the LPA met with Clinical Director, Tiffany Curtis. Entrance interview.

During the initial visit on 03/17/2025, the LPAs conducted a plant tour starting at 01:10 p.m., observed the centrally stored medications area and conducted a medications review starting at 01:20 p.m., conducted an interview with one staff at 01:00 p.m., and obtained copies of pertinent documents relevant to the investigation. On 07/09/2025, between 12:15 p.m. and 01:20 p.m., LPA Arroyo conducted interviews with three staff and two clients, conducted a medication review, and obtained copies of pertinent documents relevant to the investigation.

Report Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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 4
Control Number 29-AS-20250311091706
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: 09/09/2025
NARRATIVE
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Report Continued from LIC 9099C...

It was alleged that staff is mishandling residents’ medication and staff is not administering residents’ medication as prescribed. It was reported that there have been medication errors due to facility staff administering wrong dosages and medications not administered as prescribed. A review of clients’ medications and the Centrally Stored Medication and Destruction Records (CSMDR) revealed that medications are properly documented on the CSMDR. Interviews conducted with staff indicated that they hand the clients the medication bottle or bubble pack, and the clients self-administer their medications. Staff only document the medication as administered on the Medication Administration Records (MARs) after confirming that the client has taken the medication as prescribed. Additionally, staff reported that they review the CSMDR and MARs daily to ensure there are no medication errors. Interviews with clients confirmed that they are aware of their prescribed medications and dosages and expressed no concerns regarding receiving the wrong medication or dosage when assisted by facility staff. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “staff is mishandling residents’ medication” and “staff is not administering residents’ medication as prescribed”. Therefore, these allegations are deemed Unsubstantiated at this time.

It was also alleged that staff did not properly store medication. It was reported that medications are not being properly stored and locked up. During the facility walkthrough, the LPA observed that the medication cart is located inside the RPM’s office. Although the office was unlocked at the time due to the RPM being present, the medication cart was locked and inaccessible to clients. Interviews with facility staff confirmed that the medication cart remains locked at all times, except during active medication administration. Staff also stated that the office is kept locked whenever the RPM or their assistant is not physically present. Based on observations and interviews conducted, the Department has insufficient evidence to support the allegation of “staff did not properly store medication”. Therefore, this allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20250311091706
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: 09/09/2025
NARRATIVE
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Report Continued from LIC 9099C...

It was also alleged that staff is not adequately trained. It was reported that facility staff are not adequately trained and unqualified to be administering medications to residents and safety drills are not being conducted quarterly. Per facility program, Policy Title: Personnel Authorized for Medication Administration, it states under Procedure that “Medication is not administered by Casa staff. Residential Recovery Counselors are authorized to assist clients with medication self-administration…”. Additionally, per Policy Title: Ongoing Staff Training on it states that “this program requires all staff complete 20 hours of training on an annual basis. There are certain trainings that are required on an annual basis and these trainings are incorporated into the program for ongoing staff training”. Record review of yearly staff trainings revealed that each staff member has at least 20 hours of training that incudes medication training along with other training specific or related to their job specification. Additionally, record review of facility’s emergency disaster plan revealed that emergency disaster drills are being conducted quarterly as per regulation. Furthermore, record review and interviews conducted indicate that emergency disaster drills are being conducted at least once a month. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff is not adequately trained”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was also alleged that staff does not provide scheduled activities for residents. It was reported that there is no curriculum scheduled for residents to follow. During a facility walkthrough, the LPA observed an Activity Calendar posted in the common area, listing at least three (3) different activities scheduled each day. Additionally, clients were observed actively participating in group activities at the time of the visit. Interviews with staff revealed that a treatment plan is developed for each client, specifying the number of hours they are expected to participate in activities each week. Staff stated that clients are encouraged, but never forced to participate in specific activities. Client interviews corroborated the staff interviews, as clients confirmed that although they are given a specific number of hours to participate in each week, they are not required to join any particular activity. Additionally, clients reported that there are group activities they enjoy and look forward to participating in. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff does not provide scheduled activities for residents”. Therefore, this allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20250311091706
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: 09/09/2025
NARRATIVE
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Report Continued from LIC 9099C...

It was also alleged that staff is not keeping hallway free of obstruction. It was reported that there are brooms and other objects in the hallways creating a hazard and concern for residents’ safety. During the visit on 03/17/2025, the LPA, along with the Residential Program Manager, conducted a walkthrough of the facility. The following was observed: the facility had all cleaning supplies locked and inaccessible to residents at the time of the visit. Brooms, mops, and dust pans were observed hanging by a hallway. However, items were not observed obstructing the emergency exit. Staff interviews confirmed that all cleaning supplies are properly stored and hung when not in use. Furthermore, all hallways were observed to be clean and free of obstructions. Based on observation and interviews, the Department has insufficient evidence to support the allegation “staff not keeping hallway free of obstruction”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was further alleged that there is Insufficient staffing. It was reported that staff is rotated between facilities; however, there are not enough to cover all houses. Per facility program, Policy Title: Staffing – Pg 44, it states that one Residential Recovery Counselor is scheduled for the Casa on the day shift and two Residential Recovery Counselors are scheduled on the evening and night shifts seven days a week. During the course of the investigation, the LPA obtained and reviewed timecards and staff schedules for the month of February 2025 and conducted interviews with both staff and clients. At the time of the complaint allegation, there were at least two staff members scheduled for each shift in the AM, PM, and NOC shift. Timecard reviews confirmed that, although staff schedules varied, there was sufficient staffing to cover any unforeseen shortages. Further record review and interviews conducted revealed the availability of on-call staff, as well as the use of outside agency staffing when necessary. During interviews, staff reported no concerns regarding staffing levels, stating that they have been fully staffed for some time. Staff also indicated that there are typically two to three staff members working during each shift. In addition, the facilities use ‘floaters’ who are able to move freely throughout the facilities to provide assistance where needed. Client interviews revealed that they regularly observed at least three staff members working during each shift and reported no concerns regarding staffing or living at the facility. Furthermore, a review of Guardian records confirmed that all staff are fingerprint-cleared and associated with all on-site facilities, allowing them to pick up double shifts or work at other facilities as needed. Based on the information obtained and reviewed during the course of the investigation, the Department has insufficient evidence to support the allegation of “insufficient staffing”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4