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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202887
Report Date: 03/11/2024
Date Signed: 03/12/2024 04:35:28 PM


Document Has Been Signed on 03/12/2024 04:35 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



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: 6DATE:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jasvir PowarTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with Administrator (ADM) Jasvir Powar. LPA observed 1 staff in the facility and 6 residents in the facility.

LPA reviewed 3 residents files and 3 staff files.

LPA toured the facility inside out with ADM. Licensee, and administrator certificate were observed at the entrance. LPA inspected living room, family room, kitchen, dinning room, 1 staff live-in room, 1 office, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked. There are 3 rooms for residents, and 2 bathrooms are in facility. Non skid mats were observed in the bathroom. Room temperature was observed at 70 degree F, and hot water temperature was observed at 119 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the fire alarm, and smoke and carbon monoxide detectors, and they were working fine. First aid box, flash light were observed in the facility.

LPA inspected the backyard, there was no obstruction to block the walkway.

LPA checked the log for fire and emergency drill, the last drill was conducted on 1/25/2024.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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


Document Has Been Signed on 03/12/2024 04:35 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
CCLD Regional Office, 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: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468(c)(1)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the personal rights posters were not observed in the main entrance which poses an personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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ADM stated to send a plan of correction by the POC due date to post the personal rights posters at main entrance.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/12/2024 04:35 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
CCLD Regional Office, 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: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in that 1 out of 3 resident files did not have personal rights policy which poses a personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to provide the personal rights policy to residents for resident files.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 1 out 3 resident centrally stored medication record was observed inaccurate and not up to date, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to make resident files accurate and up to date.
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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3