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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002162
Report Date: 10/25/2023
Date Signed: 10/26/2023 05:00:24 PM


Document Has Been Signed on 10/26/2023 05:00 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:
10/25/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Grace FaundoTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Vincent Moleski and Regional Manager (RM) Stephenie Doub met with licensee Grace Faundo for a pre-scheduled office meeting via Teams. Faundo had requested this meeting to discuss a change of ownership for this facility.

Faundo said she was planning on leasing the property to a prospective licensee. RM Doub told Faundo that she may hire the prospective licensee as an administrator until their application is processed and/or develop a management agreement outlining the responsibilities of the prospective licensee and herself. Faundo will remain as the licensee until the prospective licensee's application is processed and accepted. If the prospective licensee is to be the facility's administrator, Faundo should associate the individual to the facility roster via Guardian, then provide copies of their administrator certificate, their personnel files, an LIC 308, and an updated duty statement for the facility administrator to LPA Moleski.

Doub informed Faundo that written notification must be made to facility residents prior to a change of ownership. A copy of this written notification should also be provided to LPA Moleski.

No deficiencies were cited during this meeting. A copy of this report will be emailed to Faundo to sign.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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