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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202887
Report Date: 10/18/2024
Date Signed: 10/18/2024 05:05:05 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20231228133948
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: 6DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Laura OchoaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff pushed a resident.
Facility staff does not treat resident with dignity and respect.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with staff Laura Ochoa (LO).

On 12/28/2023, the Department received a complaint with the allegations that facility staff pushed a resident and facility staff does not treat resident with dignity and respect.

On 1/3/2024, the Department conducted an initial investigation visit.

LPA interviewed ADM, 1 staff and 4 residents. LPA resident roster, LIC500, resident physician report, appraisal Needs and Service plan, food menu, Admission Agreement, and Medication Administration Records..

Continue on LIC9099-C. Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 26-AS-20231228133948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: FIVE STAR SENIOR LIVING
FACILITY NUMBER: 435202887
VISIT DATE: 10/18/2024
NARRATIVE
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Facility staff pushed a resident:
Facility staff does not treat resident with dignity and respect:
The allegations are that facility staff S1 pushed a resident R1 and yelled at the resident R1.

On 1/3/2024, LPA interviewed Administrator Jasvir Powar (ADM). ADM stated he/she did not receive any report from staff or residents regarding staff abused residents. ADM stated he/she received a phone call from a resident's family member (FM) complaining about staff abused a resident. ADM stated the facility has camera surveillance system facing outside of the building, facing living room, family room, hall way. the exit door and facing the medication cabinet. ADM stated he/she conducted an internal investigation. ADM stated he/she traced the footage of the camera surveillance system and did not find any staff abusing residents. ADM stated he/she interviewed other residents and staff and did not find anything. ADM stated staff S1 denied the allegations. ADM stated S1 is a quick responder and talks louder. ADM stated he instructed S1 to talk in soft and to behave polite to vulnerable people.

LPA interviewed staff S1. S1 denied the allegations. LPA interviewed resident R1. R1 stated no staff pushed or yelled at him/her. R1 stated he/she complained the facility staff to his/her family member before. R1 stated the facility staff treat him/her good.

LPA interviewed 4 other residents (R2 - R5). 4 out of 4 residents stated they did not see or hear any staff pushed or yelled at residents.

Based on the interviews, there is no evidence to indicate staff S1 pushed or yelled at resident R1.

Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No citations noted for today’s visit. Exit interview was conducted with staff LO. A copy of this report was provided to LO.
Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20231228133948

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: 6DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Laura OchoaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
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5
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8
9
Facility did not provide a resident with over-the-counter medication when requested .
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with staff Laura Ochoa (LO).

On 12/28/2023, the Department received a complaint with the allegation that facility did not provide a resident with over-the-counter medication when requested.

On 1/3/2024, the Department conducted an initial investigation visit.

LPA interviewed ADM, 1 staff and 4 residents. LPA resident roster, LIC500, resident physician report, appraisal Needs and Service plan, food menu, Admission Agreement, and Medication Administration Records..

Continue on LIC9099-C. Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20231228133948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: FIVE STAR SENIOR LIVING
FACILITY NUMBER: 435202887
VISIT DATE: 10/18/2024
NARRATIVE
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Facility did not provide a resident with over-the-counter medication when requested:

The allegation is that the facility did not provide a resident R1 with over the counter medication M1 when resident R1 requested.

On 1/3/2024, LPA interviewed ADM. ADM stated the facility staff administer medications to residents based on doctor's order or prescriptions. ADM stated R1's family member (FM) sent over the counter medication M1 to the facility and asked the facility to administer the medication M1 to R1. ADM stated the facility cannot administer medications to residents without doctor's order, even the over the counter medications.

ADM stated the facility provide R1's over the counter medications M1 to R1's doctor to approve. ADM stated R1's doctor approved the over the counter medications M1 to administer to R1.

LPA interviewed R1. R1 stated the staff did administer the medication M1 to him/her.

Based on the interviews, the facility staff administer the over the counter medication M1 to R1 after R1's doctor approved the medication M1.

The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with staff LO. This report was provided to review and for signature. A copy of this report was provided to LO.


Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20231228133948

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: 6DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Laura OchoaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not follow resident's special diet.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with staff Laura Ochoa(LO).

On 12/28/2023, the Department received a complaint with the allegation that facility does not follow resident's special diet.

On 1/3/2024, the Department conducted an initial investigation visit.

LPA interviewed ADM, 1 staff and 4 residents. LPA resident roster, LIC500, resident physician report, appraisal Needs and Service plan, food menu, Admission Agreement, and Medication Administration Records..

Continue on LIC9099-C. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 26-AS-20231228133948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: FIVE STAR SENIOR LIVING
FACILITY NUMBER: 435202887
VISIT DATE: 10/18/2024
NARRATIVE
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Facility does not follow resident's special diet:
The allegation is that the facility does not follow resident R1's special diet.

On 1/3/2024, LPA interviewed Administrator (ADM). ADM stated the facility did not receive R1's doctor's order for special diet. ADM stated if residents have special medical condition, the facility will call 911 or contact the residents' case managers.

Based on the review of R1's physician report dated 6/29/2023, R1 has special diet for Lactose Intolerant, Crohn's, and dental soft diet.

Lactose Intolerance should avoid Milk, Cheese, Ice Cream, Bread, Ketchup, mustard, Mayo, and chocolate.

Crohn's diet should eat smaller meals more frequently, stay hydrated and drink at least eight cups of fluids per day, and avoid foods that may increase stool output,.

Dental soft diet should consists of foods that are easy to chew and swallow to reduce the need for chewing.

ADM stated the facility did not receive R1's physician order for R1's special diet and claimed R1 does not have special diet. The facility Administrator and staff do not know R1 has special diet and did not follow R1's special diet

Based on the interviews and records reviewed, the facility does not know R1 has special diet to follow and did not provide food to R1 based on R1's special diet.

The Department has investigated the above allegations. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Citations were noted today. Please see LIC9099-D. Appeal right was provided. Exit interview was conducted with staff LO. A copy of the report was provide to LO.
Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 26-AS-20231228133948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: FIVE STAR SENIOR LIVING
FACILITY NUMBER: 435202887
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
CCR
87555(b)(7)
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87555 General Food Service Requirements (b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.
This requirements was not met as evidenced by:

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Administrator stated to submit a plan of correction by the POC due date to ensure the facility follows residers' doctors prescribed special diets.
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Based on the interviews and record reviews, the facility did not provide the special diet prescribed by resident R1's physician, this poses a potential health, safety or personal rights risk to a person in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7