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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002162
Report Date: 08/13/2021
Date Signed: 08/13/2021 12:18:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:FIVE STAR RCFE INC.FACILITY NUMBER:
347002162
ADMINISTRATOR:FAUNDO, GRACE T.FACILITY TYPE:
740
ADDRESS:6512 STAR BIRD COURTTELEPHONE:
(916) 684-8613
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 6DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Grace FaundoTIME COMPLETED:
12:20 PM
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On 8-13-21 Licensing Program Analyst (LPA) Tirzah Hubbard conducted an Annual visit and met with the Licensee Grace Faundo and Veterans Affairs (VA) Nurse Rachel Vales to discuss the purpose of the visit.
Census: 6
Staff Census: 1

LPA observed all Caregivers with Finger print clearance.

LPA toured the physical plant of the facility. LPA toured the kitchen area, bedrooms, backyard, and bathrooms. Bed room contained a dresser, night stand, lamp, bed, linen, recliner chair, trash can, and TV.

LPA toured physical plant of facility.LPA observed medication logged into MARS up to date. LPA met with S1 to discuss medication log in and schedule.

LPA observed observed 2 window screens of the facility needing replacement. LPA discussed the TA of this matter. Licensee stated, the order for the the window screens have been placed. LPA observed the invoice for documentation.

Thermostat: 70 degrees

The hot water was measured at 116 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations.

LPA Tirzah Hubbard observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: FIVE STAR RCFE INC.
FACILITY NUMBER: 347002162
VISIT DATE: 08/13/2021
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LPA requested documents to be submitted for file review:

LIC 500
LIC308
LIC 400
LIC 610



The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.



LPA observed food supplies of staple nonperishable foods. There were perishable foods for a minimum of two days that shall be maintained on the premises at all times. The sharp objects that are : Knives, forks, and spoons were locked away.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed Exit interview held, copy of report given on 8-13-21.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2