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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202887
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:49:51 PM

Document Has Been Signed on 02/24/2023 12:49 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: 0DATE:
02/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Amritpal PowarTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Steve Chang conducted a pre licensing inspection visit, and met with administrator (ADM) Amritpal Powar

The facility number plate was blocked by tree, ADM stated the facility will put a new number plate on within 5 days. No COVID posters was observed on the main entrance door. No screening station was observed at the main entrance. ADM stated ADM will put the COVID posters on the main entrance door, and put a screening station with thermometer, masks, hand sanitizer, visitor log book, and COVID questionnaires at the main entrance within 5 days.

LPA toured the facility inside and out with ADM. LPA inspected living room, family room, kitchen, dinning area, two restrooms, 4 bedrooms,, and laundry room. Medication closet, was observed locked. knives closet, and cleaning product closet were observed not locked. ADM stated ADM will put locks on for knives closet, and cleaning product closet within 5 days. All the windows and screens in the bed rooms were observed in good shape condition. Trash cans were observed with covers. No posters of washing hands for 20 seconds were observed by the sinks in kitchen and restrooms. ADM stated ADM will put posters of washing hands for 20 seconds in kitchen and restrooms within 5 days.

No paper towels with holders was observed in restrooms. ADM stated ADM will put paper towels with holders in restrooms within 5 days. PPE supplies for 30 days were observed not sufficient. ADM stated ADM will put PPE supplies for 30 days in facility within 5 days. First Aid Kit was observed in the facility. Non-skid mats and Bars were observed in restrooms.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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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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
VISIT DATE: 02/24/2023
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Room temperature was observed at 70 degree F, and hot water temperature was observed at 110 degree F.
The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm system. ADM tested the smoke and carbon monoxide detectors, and they were working fine. ADM stated the fire extinguishers were bought recently. LPA did not see the proof for the dates. ADM stated ADM will put the receipts on the fire extinguisher within 5 days. LPA inspected the backyard, there was no obstruction to block the walkway.

ADM stated the staff are all fully vaccinated and done with booster. The facility already submitted the Infection Control Plan. LPA discussed the Infection Control Plan with ADM.

Component III orientation was conducted with ADM.

No citation noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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