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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202887
Report Date: 08/22/2025
Date Signed: 09/12/2025 04:18:20 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2025 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20250506085944
FACILITY NAME:FIVE STAR SENIOR LIVINGFACILITY NUMBER:
435202887
ADMINISTRATOR:POWAR, AMRITPAL KAURFACILITY TYPE:
740
ADDRESS:14876 HERCHELL DRIVETELEPHONE:
(408) 416-7200
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
08/22/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Racheal MoslyTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff yelled at a resident while in care
INVESTIGATION FINDINGS:
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**Amended on 09/12/2025 to change the allegation finding from Substantiated to Unsubstantiated.**Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit. On 05/06/2025, the department received a complaint with the above allegation. On 05/15/2025, LPA Marrufo conducted an initial complaint investigation visit. LPA Marrufo met today with Racheal Mosly. During interview on 05/15/2025, resident R1 stated Administrator (ADM) Jesse Powar yelled at R1 while R1 was speaking on the phone with a family member.

During interview on 05/15/2025, ADM stated to have observed R1 to be wobbling and asked R1 where his/her walker was. ADM stated to have not yelled at R1. ADM stated to have a heavy tone of voice, which can sometimes sound like yelling. R1 stated to have not been aware on the day of the incident that R1 was on the phone when ADM asked R1 where his/her walker was.

See LIC9099-C page for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 26-AS-20250506085944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: FIVE STAR SENIOR LIVING
FACILITY NUMBER: 435202887
VISIT DATE: 08/22/2025
NARRATIVE
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**Amended on 09/12/2025 to change the allegation finding from Substantiated to Unsubstantiated and added interview from staff S1 conducted on 09/12/2025.**

During interview on 08/22/2025, witness W1 stated to have been speaking on the telephone with R1 when W1 heard ADM yell at R1 in a scolding tone to use his/her walker. W1 stated to have later spoken on the telephone with ADM, and ADM apologized to W1 for yelling at R1.

During interview on 09/12/2025, staff S1 stated that ADM's voice is calm and is not normally loud. S1 stated ADM's voice is not misinterpreted as yelling when it is not.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Racheal Mosly and a copy of this report and appeal rights were provided.

Page 2 of 2.

END REPORT
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20250506085944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: FIVE STAR SENIOR LIVING
FACILITY NUMBER: 435202887
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2025
Section Cited
CCR
87468.1(a)(1)
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**This LIC9099-D page is amended to remove the deficiency issued on 08/22/2025. The allegation finding was amended to be changed from Substantiated to Unsubstantiated.**
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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.
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2025 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20250506085944

FACILITY NAME:FIVE STAR SENIOR LIVINGFACILITY NUMBER:
435202887
ADMINISTRATOR:POWAR, AMRITPAL KAURFACILITY TYPE:
740
ADDRESS:14876 HERCHELL DRIVETELEPHONE:
(408) 416-7200
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
08/22/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Racheal MoslyTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
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8
9
Staff teased a resident while in care
INVESTIGATION FINDINGS:
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**Amended on 09/12/2025 to remove allegation "Resident sustained unexplained injuries while in care" and add further interview from resident R1**
During interview on 05/15/2025, R1 stated that all the staff have teased R1 about having allergies. During interview on 09/12/2025, R1 stated that staff S2, a former staff, teased R1 about R1's allergies while R1 was in the shower.

During interview on 05/15/2025, staff S1 stated to have never teased R1 about having allergies. S1 stated to have never observed another staff tease R1 about having allergies.

During interview on 05/15/2025, ADM stated to have not teased R1 about having allergies or observed a staff doing so.

See LIC9099-C page for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20250506085944
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: FIVE STAR SENIOR LIVING
FACILITY NUMBER: 435202887
VISIT DATE: 08/22/2025
NARRATIVE
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**Amended on 09/12/2025 to remove the allegation "Resident sustained unexplained injuries while in care" and the accompanying narrative for that allegation.**

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Racheal Mosly and a copy of this report was provided.
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5