Community Care Licensing

Document Has Been Signed on 03/13/2025 05:29 PM - It Cannot Be Edited

FACILITY NAME:	FIVE STAR SENIOR LIVING		FACILITY NUMBER:	435202887
ADMINISTRATOR/ DIRECTOR:	POWAR, AMRITPAL KAUR		FACILITY TYPE:	740
ADDRESS:	14876 HERCHELL DRIVE		TELEPHONE:	(408) 416-7200
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY: 6		CENSUS: 5	DATE:	03/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:10 PM
MET WITH:	Jasvir Powar		TIME VISIT/ INSPECTION COMPLETED:	04:57 PM

SUPERVISORS NAME: Romeo Manzano LICENSING EVALUATOR NAME: Chihhsien Chang LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025

Link to Parent Document Below:

FACILITY NAME: FIVE STAR SENIOR LIVING	FACILITY NUMBER: 435202887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that staff S1 works for the facility more than one month and staff S2 works for the facility more than 6 months, both wiout health screen forms. which poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	ADM stated to send plian of correction by the POC due date to ensure all staff have health screening forms ready.

SUPERVISOR'S NAME: Romeo Manzano LICENSING EVALUATOR NAME: Chihhsien Chang LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025

Link to Parent Document Below:

FACILITY NAME: FIVE STAR SENIOR LIVING	FACILITY NUMBER: 435202887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

Type B

Section Cited

CCR

87412(a)(11)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that 2 out of 3 staff without health screen forms which poses/posed a potential health, safety.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	ADM agreed to send plan of correction by the POC due date to ensure all staff have the health screen forms.

Type B

Section Cited

CCR

87465(h)(1)

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that 3 out of 3 residents' central stored medication forms without started date which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	ADM stated to submit plan of correction by the POC due date to ensure all residents' centrally stored medication forms are maintained accurate and up to date.

SUPERVISOR'S NAME: Romeo Manzano LICENSING EVALUATOR NAME: Chihhsien Chang LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025

Link to Parent Document Below:

FACILITY NAME: FIVE STAR SENIOR LIVING	FACILITY NUMBER: 435202887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that 2 out of 3 residents physician reports are more than 1 year which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	ADM stated to send plna of correction by the POC due date to maintain residents' physician reports up to date.

Type B

Section Cited

CCR

87463(i)

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that 2 out of 3 residents' appraisal needs and service plan are over than one year which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	ADM stated to send plan of correction by the POC due date to ensure residents' appraisal needs and service plans are done annually.

SUPERVISOR'S NAME: Romeo Manzano LICENSING EVALUATOR NAME: Chihhsien Chang LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025