435202887-9-12-2025-26-AS-RMAO-DMHQX9-20251016123311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202887
Report Date: 05/28/2025
Date Signed: 09/12/2025 04:14:46 PM

Unfounded

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
05/12/2025 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20250512144930

FACILITY NAME:	FIVE STAR SENIOR LIVING		FACILITY NUMBER:	435202887
ADMINISTRATOR:	POWAR, AMRITPAL KAUR		FACILITY TYPE:	740
ADDRESS:	14876 HERCHELL DRIVE		TELEPHONE:	(408) 416-7200
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	6	CENSUS: 4	DATE:	05/28/2025
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Racheal Mosley		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility staff does not apply adequate first aide to resident in care
Staff left resident outside without supervision
Staff left resident in soiled clothing for extended period

INVESTIGATION FINDINGS:

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**Amended on 09/12/2025 to change the allegations finding from Unsubstantiated to Unfounded**
Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Racheal Mosley. On 05/12/2025, the department received a complaint with the above allegations. On 05/15/2025, LPA Marrufo conducted an initial complaint investigation visit.

On 05/15/2025, LPA Marrufo conducted a telephone interview with Witness W1. W1 stated to have observed resident R1 with a bandage applied to a wound on one of R1’s arms. W1 stated to have observed that one of the adhesive bands of the bandage was over R1’s wound instead of the portion of the bandage with gauze. W1 stated to have not observed when the bandage was initially applied to R1’s wound.

See LIC9099-C pages for more information. Page 1 of 4.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025

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 4

Control Number 26-AS-20250512144930

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: 05/28/2025

NARRATIVE

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On 05/15/2025, LPA Marrufo interviewed staff S1. S1 stated to have applied a bandage to R1 after R1 experienced a fall. S1 stated to have placed the “cloth part” of the bandage on the wound. S1 stated the bandage did not move at all on R1’s arm.

On 05/15/2025, LPA Marrufo interviewed R1. R1 stated facility staff placed a bandage on R1. R1 stated the bandage was placed so that the cloth part of the bandage was over the wound. R1 stated the bandage did not become loose or move at all.

LPA Marrufo obtained a copy of R1’s Physician’s Report. R1’s Physician’s Report has an exam date of 05/18/2023. The Physician’s Report indicates R1 does not have wandering behavior, is not confused/disoriented, and is able to leave the facility unassisted, and is ambulatory.

LPA Marrufo obtained a copy of R1’s Appraisal/Needs and Services Plan, dated 04/17/2025. R1’s Appraisal/Needs and Services Plan states, “Balance issues needs a walker.” The Physical/Health section of R1’s Appraisal/Needs and Services Plan states, “Needs a walker,” and “Needs to be reminded to walk with a walker.”

During interview on 05/15/2025, W1 stated that R1 told W1 that S1 left R1 outside in the backyard of the facility without checking on R1 or opening the screen door for R1.

During interview on 05/15/2025, S1 stated that R1 and the other residents can go to the backyard of the facility on their own to smoke. S1 stated that R1 is not able to open the screen door facing the backyard of the facility on his/her own. S1 stated that although the screen door facing the backyard is closed, the garage door is left open for R1, and R1 can reenter the facility home through the garage door.

During interview on 05/15/2025, R1 stated to be able to stand up on his/her own from the metal chairs in the backyard, but not the cushioned chairs. R1 stated to have never been left in the backyard for a long time. R1 stated that if the screen door to the facility is closed, R1 will go through the garage door. R1 stated to have never been locked out of the facility. R1 stated to have been able to enter and exit the facility at will.

Page 2 of 4.

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20250512144930

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: 05/28/2025

NARRATIVE

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On 05/15/2025, LPA Marrufo interviewed Administrator (ADM) Jesse Powar. ADM stated staff keep the garage door unlocked for R1. ADM stated the glass doors to R1’s bedroom and the facility kitchen are left open and the screen doors are left closed. ADM stated R1 cannot open the glass doors independently, but can open the screen doors independently.

R1’s Physician’s Report states R1 does not have bowel impairment or bladder impairment, and is able to bathe self, dress/groom self, and care for own toileting needs.

During interview on 05/15/2025, W1 stated to have observed R1 with diapers that were soaking in urine and gushing out when R1 was sitting down. W1 stated to have made these observations of R1 in a location outside of the facility.

During interview on 05/15/2025, S1 stated that R1 will go to the bathroom by himself/herself and S1 will assist R1 with changing diapers if R1 has an accident. S1 stated that R1 does not check R1’s diapers because R1 will vocalize to S1 if R1’s diapers need to be changed. S1 states S1 assists R1 with showering. S1 stated S1 would initially shower R1 three times a week when R1 first moved into the facility, but R1 complained that the showers were drying R1’s skin, so S1 began showering R1 twice a week. S1 stated R1 has began taking showers three times a week again.

S1 stated to not change R1 unless R1 showers or has a spill or blood stain on R1’s clothes.

S1 stated to have not observed R1 in soiled clothing for an extended time.

S1 stated to have not been on duty the morning that R1 had an appointment to a location outside of the facility, but R1 told S1 that R1 urinated in the taxi on the way to his/her appointment.

During interview on 05/15/2025, R1 stated staff shower R1 every other day and change R1 after each shower. R1 stated he/she showers Mondays, Wednesdays, and Fridays. R1 stated staff change R1’s diapers every day. R1 stated staff do not leave R1 in soiled diapers for an extended time.

Page 3 of 4.

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 26-AS-20250512144930

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: 05/28/2025

NARRATIVE

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**Amended on 09/12/2025 to change the allegation finding from Unsubstantiated to Unfounded.**

R1 stated that while R1 was in a taxi about a week and a half ago, R1 urinated in R1’s diapers in the back seat of the taxi.

This agency has investigated the complaint allegations listed. Based on interviews, review of records, the CCLD has found that the complaint allegations are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Racheal Mosely and a copy of this report was provided.

Page 4 of 4.

END REPORT

SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4