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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701387
Report Date: 03/10/2025
Date Signed: 03/10/2025 02:09:32 PM

Document Has Been Signed on 03/10/2025 02:09 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: 4DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jayson CaridadTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Jayson Caridad and explained the purpose of the visit.

LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S3). LPA Moleski observed several residents had appraisals and/or needs and services plans which were not updated within the last 12 months. R1's appraisal and their needs and services plan were dated 08/15/2023, when R1 was admitted. R3's appraisal was undated, but appeared to have been completed when the resident was admitted, around 06/01/2023. R4's appraisal was dated 11/29/2022, when the resident was admitted. LPA Moleski observed that S3's first aid/CPR certification expired as of 10/08/24. While speaking with Caridad, LPA Moleski learned that a resident (S5) had died in mid-February 2025. LPA Moleski asked if there was a death report submitted at the time. Caridad said there was not. LPA Moleski asked to review recent emergency disaster drill records. Caridad said drills had not been conducted or documented.

LPA Moleski toured the facility with Caridad and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 108 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguishers, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed locked cabinets for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed two staff members (S1-S2) and two residents (R2, R4). This facility is hereby cited per 22 CCR Sections 87463(a), 87211(a)(1), and 87411(c)(1), and HSC Section 1569.695(c). An exit interview was held with Caridad. Appeal rights and a copy of this report were left with Caridad.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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 03/10/2025 02:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/10/2025 at 01:42 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FIVE STAR RCFE 1 INC
FACILITY NUMBER: 342701387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, a death report was not submitted for R5, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with R5's death report and with a statement acknowledging reporting requirements by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, at least one staff member had expired first aid/CPR certification, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with an updated first aid/CPR certification for all outstanding staff members by POC due 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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/10/2025 02:09 PM - It Cannot Be Edited


Created By: Vincent Moleski On 03/10/2025 at 01:42 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: FIVE STAR RCFE 1 INC
FACILITY NUMBER: 342701387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, multiple residents had expired appraisals/needs and services plans, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with updated and signed appraisals and needs and services plans for all four residents by POC due date.
vincent.moleski@dss.ca.gov
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, emergency disaster drills were not conducted and/or recorded, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with a written acknowledgement of this requirement, and a schedule of planned drills for the remainder of this year by POC due date.
vincent.moleski@dss.ca.gov
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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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