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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002162
Report Date: 08/02/2023
Date Signed: 08/02/2023 04:03:04 PM


Document Has Been Signed on 08/02/2023 04:03 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: DATE:
08/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Grace FaundoTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a deficiency cited during this facility's annual inspection on 6/29/23. LPA Moleski met with administrator Grace Faundo and explained the purpose of the visit.

LPA Moleski did not receive a plan of correction for this deficiency. Faundo showed LPA Moleski that she had sent a plan of correction to another LPA. LPA Moleski will clear Faundo's deficiency.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Faundo.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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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