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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202887
Report Date: 02/10/2023
Date Signed: 02/10/2023 10:49:09 AM

Document Has Been Signed on 02/10/2023 10:49 AM - 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
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: DATE:
02/10/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Amritpal Kaur Powar, CEO/administrator/owner; Jasvir (Jesse) Powar, administrator/ownerTIME COMPLETED:
10:21 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
COMP II Participants: Amritpal Kaur Powar, CEO/administrator/owner; Jasvir (Jesse) Powar, administrator/owner
Interview Method: Telephone interview

On 2/10/23, applicants/administrators participated in COMP II. Identification of the applicants/administrators was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicants/administrators confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicants/Administrators understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Anna Barrios
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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