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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202117
Report Date: 11/15/2024
Date Signed: 11/15/2024 05:37:03 PM

Document Has Been Signed on 11/15/2024 05:37 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SILVER STAR RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202117
ADMINISTRATOR/
DIRECTOR:		FE.O.PUNZALANFACILITY TYPE:
735
ADDRESS:5130 SAN FELIPE RD.TELEPHONE:
(408) 270-6005
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY: 6CENSUS: 5DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Fe PunzalanTIME VISIT/
INSPECTION COMPLETED:
05:36 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced annual inspection visit, and met with Fe Punzalan. During the visit, LPA observed 5 residents and 3 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkway or ramps.
During inspection LPA observed a locked Shed used as storage and not as a living space.

LPA observed two day perishable food supplies and seven day nonperishable food supplies. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, kitchen hot water was measured with thermometer at 104.1 degrees F and 105 degrees F in resident bathroom.
During inspection of Staff (S1) unlocked bedroom LPA observed medication bottle containing tablets belonging to S1 and accessible to residents in care.

Fire extinguisher was serviced in 03/16/24. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 10/19/2024

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records and P & I money . LPA conducted interviews with 1 staff and 1 residents.

Deficiencies cited during today's visit see 809-D. This report was reviewed with Fe Punzalan and a copy of the signed report was provided and appeals rights.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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Document Has Been Signed on 11/15/2024 05:37 PM - It Cannot Be Edited


Created By: Marcela Yanez On 11/15/2024 at 05:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SILVER STAR RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above LPA observed staff bedroom was unlocked and inside staff bedroom was medication containing tablets accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2024
Plan of Correction
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ADM will conduct a in-service how to make sure the staff lock the staff bedrooms and make sure medication is inaccessible to residents in care and provide documentation training has taken place.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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