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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415201625
Report Date: 06/17/2024
Date Signed: 06/17/2024 11:27:34 AM


Document Has Been Signed on 06/17/2024 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:FIVE STAR CARE HOMEFACILITY NUMBER:
415201625
ADMINISTRATOR:MELKONYAN, EVELINAFACILITY TYPE:
740
ADDRESS:416 LANYARD DRIVETELEPHONE:
(650) 592-6333
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY:6CENSUS: 6DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver - Lorna TorresTIME COMPLETED:
11:35 AM
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On 06/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with caregiver Lorna Torres and explained the purpose of today's visit. There is 1 staff present and 6 residents present. 5 of the residents are still in bed but one is awake and interacting freely in the facility. A second caregiver is on duty as well but is picking up resident medications per Lorna.

LPA was allowed entry into the facility. This is a single level facility. Annual fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer adjacent to the stove top. Medications are also locked in the kitchen in a cabinet. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed that there is one fire extinguisher in place in the dining room last inspected 03/28/2024, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located in the garage area. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 107F. Shower floor uses non-skid mat when shower is in use. LPA observed all residents rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FIVE STAR CARE HOME
FACILITY NUMBER: 415201625
VISIT DATE: 06/17/2024
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LPA reviewed 3 client files and also reviewed 3 staff files on this day. Per resident files reviewed they are incomplete and not current. Needs and appraisal plans are not completed as well as other items such as current physician reports as several are from when the resident was admitted to the facility. Per staff files reviewed, staff do not have current first aid cards on file. These discoveries pose a potential health and safety risk and a citation is issued. P&I is not handled by the facility. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as expired on 12/23/2022 but has submitted the renewal but has not received the new license per licensee phone call made during today's visit.

The following updated forms are requested to be submitted to CCLD by 06/24/2024:

• Copy of updated Administrator Certificate
• LIC308 Designation of responsible staff person
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610D Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property such as lease agreement with expiration date

Citations issued on attached LIC809D. Report is reviewed with caregiver Lorna and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/17/2024 11:27 AM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: FIVE STAR CARE HOME
FACILITY NUMBER: 415201625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2024
Section Cited
CCR
87506(a)

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87506 Resident Records:(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This regulation has not been met as evidenced by:
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The licensee shall develop a plan in writing on how she will correct this citation to maintain current records for all residents at all times.
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Based on resident records reveiwed, 3 resident files are not current. Needs and appraisal plans are not completed as well as other items such as current physician reports as several are from when the resident was admitted to the facility. This can pose a potential health and safety risk to residents in care.
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POC due by 06/24/2024
Type B
06/24/2024
Section Cited
CCR80075(f)

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80075(f) Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This regulation has not been met as evidenced by:
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The licensee shall submit proof that all staff, including the licensee, will receive current first aid training and provide copies of first aid cards as part of the correction.
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Based on faciltiy staff files reviewed, 3 of 3 staff files indicate that first aid cards expired on 05/2024. This can pose a potential health and safety risk for residents in care.
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POC due by 06/24/2024
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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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