565801434-8-28-2023-29-AS-KDUK-CV65EP-20230828195351

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801434
Report Date: 08/28/2023
Date Signed: 08/28/2023 07:53:59 PM

Document Has Been Signed on 08/28/2023 07:53 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:	STARSHIP		FACILITY NUMBER:	565801434
ADMINISTRATOR:	JESUS CARDENAS		FACILITY TYPE:	772
ADDRESS:	1760 SOUTH LEWIS ROAD		TELEPHONE:	(805) 383-3669
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93012
CAPACITY: 15		CENSUS: 13	DATE:	08/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Ayana Churn		TIME COMPLETED:	08:00 PM

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) Kelly Dulek conducted a required annual visit and inspection. LPA met with Program Director Ayana Churn. Entrance interview conducted. Beginning at 01:02PM, the LPA, along with Administrator Jordan Ward 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: Fire extinguisher was observed to be fully charged and last serviced 11/16/2022. Carbon Monoxide detector was tested at 01:34PM and was functional at the time of the visit. Fire inspection conducted 06/21/2023 reflected no violations at that time. MEDICATIONS: Medications for five (5) clients were observed beginning at 12:48PM. All medications reviewed were stored and documented per regulation. BEDROOMS: There were 15 bedrooms designated for client use. Ten (10) client bedrooms were observed during today's visit. All bedrooms observed were furnished for single occupancy and were properly furnished, including adequate supplies of bedding and linen. No visible hazards were observed. BATHROOMS: Each of the bedrooms observed included an individual half bathroom equipped with a sink and commode. All bathrooms observed 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 and all tested within the required range of 105 to 120 degrees Fahrenheit. Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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 08/28/2023 07:53 PM - It Cannot Be Edited

Created By: Kelly Dulek On 08/28/2023 at 06:17 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: 08/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81075(f)

Health-Related Services

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as two (2) of five (5) staff files reviewed did not contain proof of first aid training, which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/15/2023
	Plan of Correction
1 2 3 4	Program Director agreed to provide training for the 2 staff identified (Staff #1 and Staff #2) and provide proof of training to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 08/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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: 08/28/2023

NARRATIVE

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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. Knives and sharps are stored in a locked cabinet. There was an adequate supply of perishable and nonperishable food to accommodate 15 clients for one week.

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. There is also a laundry room, which clients utilize. All hazardous cleaning chemicals were observed to be stored in a locked staff restroom.

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.

RECORD REVIEW: Beginning at 12:14PM, LPA reviewed staff and client files for but not limited to: client Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All five (5) client files reviewed contained all required documents. LPA reviewed five (5) staff files. Four (4) of five (5) staff files reviewed did not contain a complete 20 hours annual training. Two (2) staff files did not contain proof of first aid training. LPA obtained documents to update the facility Administrator.

INTERVIEWS: During today's visit, LPA interviewed three (3) clients.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Disaster drills are conducted monthly, with the most recent drill documented on 08/15/2023.

Pursuant to Title 22 Division 6 Chapter 2 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-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: 08/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC809 (FAS) - (06/04)

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