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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202887
Report Date: 09/12/2025
Date Signed: 09/12/2025 04:17:16 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
05/06/2025 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20250506085944
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:
09/12/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Racheal MoselyTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Racheal Mosely. On 05/06/2025, the department received a complaint with the above allegation. LPA conducted complaint investigation visits on 05/15/2025 and 08/22/2025.

LPA Marrufo obtained copies of R1’s After Visit Summary from hospital visits on 05/02/2025 and 05/07/2025. The After Visit Summary from 05/02/2025 states the issue addressed during the visit was “easy bruising.” The After Visit Summary from 05/07/2025 states the issue addressed during the visit was "multiple open wounds."

During interview on 05/15/2025, resident R1 stated to have had a fall that occurred about a month and a half ago that resulted in R1 experiencing bruising. R1 stated after the fall, staff helped R1 and called for an ambulance to take R1 to the hospital. See LIC9099-C page for more information. Page 1 of 2.
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 2
Control Number 26-AS-20250506085944
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: 09/12/2025
NARRATIVE
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During interview on 05/15/2025, staff S1 stated that R1 had a fall about a week prior to the interview. S1 stated R1 already had scabs on R1’s arms and the scabs were opened after R1’s fall. S1 stated to have wrapped R1’s open scabs and sent R1 to urgent care.

During interview on 05/15/2025, administrator (ADM) Jesse Powar stated that the facility staff have addressed R1’s bruising. ADM stated that on prior incidents, staff have offered to take R1 to the hospital, but R1 has refused because R1 doesn’t want to be prevented from smoking at the hospital.

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

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


Page 2 of 2.



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: 2 of 2