415201625-8-1-2022-14-AS-KCHA-CGVTY5-20220801150809

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415201625
Report Date: 08/01/2022
Date Signed: 08/01/2022 03:08:32 PM

Document Has Been Signed on 08/01/2022 03:08 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	FIVE STAR CARE HOME		FACILITY NUMBER:	415201625
ADMINISTRATOR:	MELKONYAN, EVELINA		FACILITY TYPE:	740
ADDRESS:	416 LANYARD DRIVE		TELEPHONE:	(650) 592-6333
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94065
CAPACITY:	6	CENSUS: 5	DATE:	08/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Caregiver, Lorna Torres		TIME COMPLETED:	03:15 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	On August 1, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA did not observe COVID-19 signage posted at the front entrance. LPA met with Caregiver, Lorna Torres and explained the purpose of the visit. LPA was not screened at entry point and Caregiver was not able to provide LPA screening log documentation for visitors or staff. In addition, Caregiver indicated that she takes resident's temperatures, however does not document it. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 6 resident bedrooms, 1 staff bedroom, 2 full bathrooms, and 4 half bathrooms. LPA observed all resident bedrooms to be private rooms. Bathrooms were observed to be equipped with liquid soap, paper towels, and a covered trash can. LPA advised caregiver to put a hand washing sign in the bathrooms and remove all bath-towels and bar soaps from the communal bathrooms. Infection control practices are not present: entry procedures, and daily monitoring log for residents, visitors, and staff. LPA observed the 30-day PPE supply present at the facility. LPA toured the living room and dining room and it was clear and free from any tripping hazards. A comfortable temperature at 75 degrees F is maintained, lighting is sufficient for comfort. LPA toured the kitchen, medications, toxins and sharps are stored appropriately and inaccessible to residents. LPA observed 2 day perishable and 7 day non-perishable present. LPA advised caregiver to ensure there are no hand-towels in the kitchen. Extra linen was observed to be present. LPA toured the garage and observed the washer and dryer to be in good working condition. Extra food supply was present in the garage. CONT. to 809C

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FIVE STAR CARE HOME	FACILITY NUMBER: 415201625
	VISIT DATE: 08/01/2022

NARRATIVE

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LPA requests the following to be submitted to CCLD by 8/8/22:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan
-Administrator Certificate

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Caregiver, and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 08/01/2022 03:08 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
SF COASTAL AC/SC, 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: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. The facility failed to provide documentation for the daily residents and staff members screening log; the facility failed to provide documentation for the visitor's screening log, facility failed to post COVID sign on front door.
	POC Due Date: 08/08/2022
	Plan of Correction
1 2 3 4	The Administrator and/or designee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening process for visitors, residents and staff members and start documenting the results of the screening outcomes on a log to indicate that it was done. The Administrator will in-service staff members on this procedure and the Administrator will provide a copy of the sign-in sheet and the required logs to the Department by 8/8/22. Administrator to send LPA picture of the front door with signs

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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