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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801434
Report Date: 09/27/2021
Date Signed: 09/27/2021 04:48:47 PM

Document Has Been Signed on 09/27/2021 04:48 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:STARSHIPFACILITY NUMBER:
565801434
ADMINISTRATOR:JOHN FRIEDECKFACILITY TYPE:
772
ADDRESS:1760 SOUTH LEWIS ROADTELEPHONE:
(805) 383-3669
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY: 15CENSUS: 14DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jennifer Beltran & Denise GonzalezTIME COMPLETED:
03:37 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a required annual visit and inspection. LPA initially met with office staff Jennifer Beltran and Denise Gonzalez. Administrator John Friedeck joined for the facility tour at 11:55am. Program Director Christopher Blum was unavailable today.

A tour of the physical plant was initiated at 11:30am. LPA was accompanied by the office staff.

KITCHEN: The facility is equipped with two separate kitchens designated as Kitchen A and Kitchen B. Both kitchens were equipped with fixtures and appliances that appeared clean and functional. There was an adequate supply of perishable food to accommodate 15 clients for two days and nonperishable food to accommodate 15 clients for one week.

BEDROOMS: There were 15 bedrooms designated for client use. All bedrooms were furnished for single occupancy and were properly furnished and had adequate supplies of bedding and linen. No visible hazards were observed.

BATHROOMS: Each of the 15 bedrooms included an individual half bathroom equipped with a sink and commode. All bathrooms were properly supplied with paper products and personal hygiene items and fixtures were observed to be functional at the time of the visit. There was one bathroom located in the main entrance designated for staff use only. There were four shower rooms, two at each end of the facility designated for client use.

COMMON AREAS: These included two dining areas, one adjacent to each Kitchen and designated as A and B. There were two Living Rooms, one adjacent to each dining area also designated as A and B. All common areas were adequately furnished to accommodate a maximum capacity of 15 clients.
Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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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Document Has Been Signed on 09/27/2021 04:48 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/27/2021 at 03:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARSHIP
FACILITY NUMBER: 565801434

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81068.4(b)
Admission and Retention Limitations
(b) A client's length of stay shall not exceed 18 months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 14 clients in care has been retained in the facility for over 20 months, which poses a potential personal rights risk to persons in care.
POC Due Date: 10/01/2021
Plan of Correction
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Facility designees agreed to discuss the plan with the Administrator and Program Director upon their return to the facility. Administrator and/or Program Director will contact LPA by 10/1/2021 with a plan of discharge for the client.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2021


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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: STARSHIP
FACILITY NUMBER: 565801434
VISIT DATE: 09/27/2021
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SURROUNDING GROUNDS: The surrounding grounds included Parking Lots, Walkways, and Lawns. There were various shady areas available for clients. There were no immediate or imminent hazards observed.

FILE REVIEW: Beginning at 2:20pm, LPA reviewed the client roster and 3 client files. LPA observed that Client #1 (C1) was admitted to the facility on 1/15/2020 and has been retained in the facility since C1’s admit date.

INFECTION CONTROL: During today’s visit, the LPA spoke with the office staff regarding the facility’s infection control practices at 2:55pm. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room and shower room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

At the conclusion of the visit, facility office staff/designees Jennifer Beltran and Denise Gonzalez met with LPA; exit interview conducted. Citations issued. A copy of report and appeal rights were provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
LIC809 (FAS) - (06/04)
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