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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801434
Report Date: 09/26/2022
Date Signed: 09/26/2022 01:29:40 PM

Document Has Been Signed on 09/26/2022 01:29 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:JESUS CARDENASFACILITY TYPE:
772
ADDRESS:1760 SOUTH LEWIS ROADTELEPHONE:
(805) 383-3669
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY: 15CENSUS: 13DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Jennifer Beltran & Denise GonzalezTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a required annual visit and inspection. This annual had a specific emphasis on infection control practices and procedures. The Administrator was unavailable during today's visit. Office staff are designated to sign all reports. Entrance interview conducted.

The LPA, along with facility office staff Jennifer Beltran, beginning at 10:40AM toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

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 nonperishable food to accommodate 15 clients for one week. Supply of perishable fruits was low at the time of the visit, however, facility staff stated shopping occurs weekly on Mondays and Thursdays. During the visit, additional food was obtained and facility was in compliance.

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 were four shower rooms, two at each end of the facility designated for client use. Water temperature was measured in various bathrooms throughout the facility.
Report Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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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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: 09/26/2022
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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. Fire extinguishers observed throughout the facility were fully charged and last serviced 12/01/2021.

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.

INFECTION CONTROL: During today’s visit, the LPA spoke with the office staff regarding the facility’s infection control practices. 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/designee Jennifer Beltran met with LPA; exit interview conducted. No citations issued. A copy of report was provided via email.

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

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC809 (FAS) - (06/04)
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