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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801434
Report Date: 10/24/2024
Date Signed: 10/24/2024 02:26:10 PM

Document Has Been Signed on 10/24/2024 02:26 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/
DIRECTOR:		JORDAN WARDFACILITY TYPE:
772
ADDRESS:1760 SOUTH LEWIS ROADTELEPHONE:
(805) 383-3669
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY: 15CENSUS: 14DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jordan WardTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted a required annual inspection today at 10:00am. Upon arrival, LPA met with Program Manager, Jordan Ward and explained the reason for the visit. Entrance interview conducted.

At 10:10am, the LPA along with Program Manager, 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. Kitchen A is used to cook clients’ meals by staff. Kitchen B is used by clients to store their own food as well as leftovers. Kitchens were equipped with fixtures and appliances that appeared clean and functional. Knives and sharps are stored in a locked cabinet in Kitchen A. There is a sufficient supply of perishable and non-perishable food. Refrigerator and pantry were checked for proper labels and expiration dates and food labels.

BEDROOMS: There were 15 bedrooms designated for client use. Client bedrooms were observed to be designated for single occupancy and were properly furnished, including adequate supplies of bedding and linen, with sufficient lighting.

BATHROOMS: Each client bedrooms includes an individual half bathroom. 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. LPA observed four (4) showers designated for client use. Starting at 10:17am, the hot water temperature was measured in various bathrooms throughout the facility, and they measured between 115.1 degrees Fahrenheit and 118.2 degrees Fahrenheit.
Report Continued on LIC 809C...
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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: 10/24/2024
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Report Continued from LIC 809...

COMMON AREAS: Common areas include two (2) dining areas and two (2) living rooms. All common areas were adequately furnished for client use. There is also a laundry room, which clients utilize. Staff provide cleaning detergent upon request. All hazardous cleaning chemicals were observed to be stored, locked, and inaccessible to clients at the time of the visit.

SURROUNDING GROUNDS: There are several shaded areas with adequate furniture for client use.

MEDICATIONS: A medications review of four (4) randomly selected clients was conducted. Medication are stored in a locked cart inside the Program Managers office. All medications reviewed were stored and documented per regulation.

RECORD REVIEW: LPA reviewed Client Records at 10:40am and Personnel Records at 12:10pm.

Seven (7) client files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order.

Five (5) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff files were complete.

INTERVIEWS: During today's visit, the LPA interviewed one (1) staff.



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. There are several fire extinguishers throughout the facility; they all were fully charged and were last serviced 11/19/2023. The last fire safety inspection was completed on 08/05/2024 and was found to have one (1) violation which was corrected on 09/18/2024. Emergency disaster drills conducted quarterly as per regulation; the last one conducted 10/15/2024.

No citations issued. Exit interview conducted. Report was reviewed and issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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