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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600705
Report Date:
06/17/2024
Date Signed:
06/18/2024 01:55:59 PM
Document Has Been Signed on
06/18/2024 01:55 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
FIVE STAR CARE HOME II
FACILITY NUMBER:
415600705
ADMINISTRATOR:
MELKANYAN, EVELINA
FACILITY TYPE:
740
ADDRESS:
789 NIANTIC DRIVE
TELEPHONE:
(650) 345-5784
CITY:
FOSTER CITY
STATE:
CA
ZIP CODE:
94404
CAPACITY:
6
CENSUS:
6
DATE:
06/17/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:40 PM
MET WITH:
Caregiver, Irma Perez
TIME COMPLETED:
03:40 PM
NARRATIVE
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On June 17, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Irma Perez and LPA explained the purpose of the visit. The administrator, Evelina Melkanyan arrived shortly thereafter.
LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. LPA observed a bed was blocking the outdoor passageway. A tour of resident's room was conducted and observed to have sufficient furniture and furnishings. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort.
Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.
Hot water temperature in the kitchen and bathroom were measured at 106-115 degrees Fahrenheit. Fire extinguishers were checked.
A review of (6) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.
The following documents were requested submitted to CCL by 6/24/24:
- LIC 500, Liability Insurance, Administrator Certification
Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. .
This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISOR'S NAME:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Murial Han
TELEPHONE:
(619) 209-9761
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
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8
Document Has Been Signed on
06/18/2024 01:56 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
FIVE STAR CARE HOME II
FACILITY NUMBER:
415600705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 out of 2 staff did not have a valid First Aid Certification which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/18/2024
Plan of Correction
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2
3
4
The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/18/2024.
Type A
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 residents did not have a pre-admission appraisal which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/18/2024
Plan of Correction
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2
3
4
The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/18/2024.
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 Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Murial Han
TELEPHONE:
(619) 209-9761
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)
Page:
2
of
8
Document Has Been Signed on
06/18/2024 01:56 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
FIVE STAR CARE HOME II
FACILITY NUMBER:
415600705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide proof that emergency drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/18/2024
Plan of Correction
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3
4
The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/18/2024.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Murial Han
TELEPHONE:
(619) 209-9761
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)
Page:
3
of
8
Document Has Been Signed on
06/18/2024 01:56 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
FIVE STAR CARE HOME II
FACILITY NUMBER:
415600705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a hold in the wooden deck which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/2024. The administrator will provide photo to proof that the wooden deck has been fixed by 6/24/2024
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 staff did not have documents to proof that required training was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/18/2024 along with a copy of the training records.
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 Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Murial Han
TELEPHONE:
(619) 209-9761
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)
Page:
4
of
8
Document Has Been Signed on
06/18/2024 01:56 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
FIVE STAR CARE HOME II
FACILITY NUMBER:
415600705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(d)(1)
Other Provisions
(1) A licensed or certified health professional with valid certification shall receive eight hours of training on resident characteristics, resident records, and facility practices and procedures prior to providing direct care to residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 staff members did not have documents to proof that this training was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2024
Plan of Correction
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2
3
4
The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24 and a copy of the training records.
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 staff did not have documents to proof that this training was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24 and a copy of the training records.
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 Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Murial Han
TELEPHONE:
(619) 209-9761
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)
Page:
5
of
8
Document Has Been Signed on
06/18/2024 01:56 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
FIVE STAR CARE HOME II
FACILITY NUMBER:
415600705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 2 out of 2 staff members did not have training records to proof that this was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24 and a copy of the training records.
Type B
Section Cited
CCR
87468(d)
Personal Rights of Residents
(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA did not observe the personal rights were posted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24. The administrator will provide photos to proof compliance.
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 Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Murial Han
TELEPHONE:
(619) 209-9761
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)
Page:
6
of
8
Document Has Been Signed on
06/18/2024 01:56 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
FIVE STAR CARE HOME II
FACILITY NUMBER:
415600705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 residents did not have a completed appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24 and a copy of the completed appraisal.
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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Murial Han
TELEPHONE:
(619) 209-9761
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)
Page:
7
of
8
Document Has Been Signed on
06/18/2024 01:56 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
FIVE STAR CARE HOME II
FACILITY NUMBER:
415600705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
This requirement is not met as evidenced by:87307 Personal Accommodations and Services
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a bed that was blocking the outdoor passageway which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/24/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure compliance and the plan shall include staff training. The administrator will provide a copy of the plan and staff training records to CCL by 6/24/2024.
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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Murial Han
TELEPHONE:
(619) 209-9761
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)
Page:
8
of
8