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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002162
Report Date: 06/29/2023
Date Signed: 06/29/2023 12:36:22 PM


Document Has Been Signed on 06/29/2023 12:36 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
SACRAMENTO AC/SC, 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: 5DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Grace FaundoTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski spoke with facility administrator Grace Faundo over the phone and explained the purpose of the visit.

LPA Moleski reviewed three resident files (R1-R3) and three staff files (S1-S3).

LPA Moleski toured the facility with staff and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 125 degrees Fahrenheit, which in not within the required range of 105 and 120 degrees. LPA Moleski and S1 observed the reading of 125 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed locked cabinets for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed two staff members (S1, S3) and one resident (R2).

This facility is being cited per 22 CCR Section 87303(e)(2). An exit interview was held with Faundo over the phone and a copy of this report was left with staff. Staff member Vilma Tumale signed this report in Faundo's absence.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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 06/29/2023 12:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: FIVE STAR RCFE INC.
FACILITY NUMBER: 347002162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure water temperatures remain below 120 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Licensee agrees to adjust water temperature and re-test until a reading between 105 and 120 degrees is achieved. Licensee agrees to send LPA Moleski a photo of the new reading.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
LIC809 (FAS) - (06/04)
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