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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701387
Report Date: 04/22/2024
Date Signed: 04/22/2024 03:16:23 PM

Document Has Been Signed on 04/22/2024 03:16 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FIVE STAR RCFE 1 INCFACILITY NUMBER:
342701387
ADMINISTRATOR/
DIRECTOR:		CARIDAD, AMY ROSEFACILITY TYPE:
740
ADDRESS:6512 STAR BIRD CTTELEPHONE:
(916) 271-2075
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 3DATE:
04/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:37 AM
MET WITH:Amy Rose and Jayson CaridadTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 4/22/24, at 10:37am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a pre-licensing visit. LPA initially met with a staff on duty and explained the purpose of the visit. The licensee and administrators, Amy Rose Caridad, Jayson Caridad and Grace Foundo were notified of the visit and arrived shortly after. During this visit, present were 2 residents in care with 2 staff on duty. The facility has an approved hospice waiver for 4 residents. Additionally, the facility is fire cleared for 6 non-ambulatory residents.

PHYSICAL PLANT:
At 10:45am, LPA and staff on duty toured the physical plant of the facility. The facility is a single-story home located in a residential neighborhood. Physical plant is consistent with the submitted facility sketch/floor plan. Facility temperature was observed to be at 79 degrees F upon arrival. Indoor and outdoor passageways are free of obstruction. Entrances/exits, ramps, open porches and backyard are well-lit. There are no bodies of water was observed. The side gate is self-latching and in good repair. Disinfectants, cleaning supplies, toxic products, and sharp objects were all observed to be locked and inaccessible to resident in care. Fire alarm and carbon monoxide detectors were observed to be operating properly. The backyard is secure and has adequate space for outdoor activities. LPA observed laundry supplies and equipment including washer and dryer and are observed to be in good repair.

BEDROOMS:
There are 6 resident bedrooms and 1 staff room. All bedrooms were observed to be fully furnished, clean and in good repair. There is appropriate lighting in the facility and in each room. Residents bedrooms were observed to be large enough to allow passage between and comfortable usage of beds and other required furniture. Currently 3 of the 6 resident bedrooms are unoccupied.

Con't to LIC809-C...

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FIVE STAR RCFE 1 INC
FACILITY NUMBER: 342701387
VISIT DATE: 04/22/2024
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BATHROOM:
There is one bathroom in the master bedroom and one bathroom in the hallway. Hot water temperatures were taken in both bathrooms and are within regulatory temperature between 105-120 degrees F. Bathtubs, showers and toilets have grab bars. Showers are equipped with non-skid flooring.

SUPPLIES:
There is a sufficient supply of hygiene items such as soap and toilet paper. The facility maintain an adequate supply of clean linen, including beddings, bath towels, hand towels and wash cloths.

ACTIVITIES:
Facility is observed to have adequate activity supplies and equipment for residents, including access to internet. There is an outdoor activity area equipped for outdoor use. There is a comfortable and appropriately furnished area for residents to entertain friends and relatives.

FOOD SERVICE:
Kitchen and dining room were observed to be clean, sanitary and odorless. Trash cans were observed to have lids. Kitchen areas were observed to be clean, and free of litter, vermin and insects. Food preparation areas have operating ventilation. Toxic substances and cleaning supplies were observed to be properly stored, locked and inaccessible to residents. Freezer was observed to be at 0 degrees F. Refrigerator was observed to be at 40 degrees F. The facility maintains a 7 day non-perishable and 2 day perishable food supply.

RECORDS:
There is a confidential storage of personnel and resident records at the facility. LPA reviewed 3 resident files and 6 staff files. 3 out of 3 resident files were observed to be within regulatory standard. Technical advisory was provided to obtain and include PRN Authorization in the resident files. 6 of 6 staff files were observed to be within regulatory standard including having current first aid/CPR certificates.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: FIVE STAR RCFE 1 INC
FACILITY NUMBER: 342701387
VISIT DATE: 04/22/2024
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MEDICATION:
LPA observed medications to be centrally stored, locked and inaccessible to residents in care. LPA conducted a medication audit for 2 residents. Audited medications were observed to be complete and are recorded in the centrally stored medication record. LPA observed first aid kit, including dressings, bandages, thermometer, scissors, tweezers, and current first aid manual.

ADMINISTRATION:
Facility is observed to have Theft and Loss Program poster. Also observed were Licensing Complaint Poster and Resident Personal Rights poster.

DEMENTIA CARE:
Heating devices including the fireplace are inaccessible to residents in care. Outdoor activity space is completely enclosed by a fence with self-closing latches and gates. Every exit has an auditory device in place to monitor exits.

COMPONENT III:

Conducted at the Pre-Licensing visit, on 4/22/24 at Five Star RCFE Inc 1, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted with Jayson Caridad, and a copy of this report was provided. Accordingly, LPA Villanueva will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
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