347002162-7-21-2022-27-AS-RWAE-CGJTCF-20220721143639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347002162
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:36:43 PM

Document Has Been Signed on 07/21/2022 02:36 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, 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 COURT		TELEPHONE:	(916) 684-8613
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	6	CENSUS: 3	DATE:	07/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Grace Faundo - Administrator		TIME COMPLETED:	03:00 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) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA explained purpose of visit to Administrator. This facility does have a hospice waiver that was approved to accept up to (2) residents under hospice at any given time. Current census is 3 residents. Tour of the facility was conducted along with administrator. Common areas were toured. Living area, recreation area, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were in good repair and able to meet the needs of the residents at this time. Kitchen area was toured. Cabinets and drawers were opened and the contents were reviewed to make sure that there was an ample supply of cups, dishes, and all other items able to meet the needs of the residents at this time. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable food quantities. First aid kit was reviewed and observed to contain all required components at this time. Fire extinguisher was observed to have been annually inspected by the local fire extinguisher company and in compliance at this time. A tour of the resident bedrooms and restrooms was conducted. Grab bars and non-skid mats/surfaces were observed to be present and in good repair at this time. Hot water temperature was measured in one of the restrooms at 108.5 F' which is within the allowed range of 105-120 degrees. Laundry room was toured. It was observed that laundry detergents, cleaners, and cleaning supplies were locked and made inaccessible to the residents at this time. Continued on 809-C

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: FIVE STAR RCFE INC.	FACILITY NUMBER: 347002162
	VISIT DATE: 07/21/2022

NARRATIVE

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Continued from 809 - Page 2

A review of the medications for the residents, stored in a kitchen cabinet, was conducted. A review of the facility Medication Administration Record, dispensing log, and Control Book for narcotics was conducted.

Linen closet was reviewed and observed to contain a sufficient supply of sheets, blankets, and covers in order to properly meet the needs of the residents at this time.
Exterior grounds of this facility was toured. A review was conducted in regards to the facility perimeter fence and side gates.

A review of (3) facility personnel records was conducted. A review of (2) facility resident records was conducted. All required documents for CCL were present in files.

There were no deficiencies observed or cited during todays' annual visit.

Exit Interview conducted with staff and a copy of report left at facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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