435202887-2-27-2026-26-AS-MMOR-DRQ2PM-20260227163434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202887
Report Date: 02/27/2026
Date Signed: 02/27/2026 04:35:04 PM

Document Has Been Signed on 02/27/2026 04:35 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	FIVE STAR SENIOR LIVING		FACILITY NUMBER:	435202887
ADMINISTRATOR/ DIRECTOR:	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: 6	DATE:	02/27/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:25 AM
MET WITH:	Administrator Amritpal Kaur Powar		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff S1 Esha Dhiman. During the visit, LPA observed 6 residents and 2 staff. LPA explained the purpose of the visit. S1 contacted facility Administrator Amritpal Kaur Powar. ADM stated had a prior appointment and stated S1 can assist LPA with the annual inspection. LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 3 residents bedrooms. There was no obstruction to block the walkways. The staff area of the facility was also inspected. The front yard and backyard were inspected. While touring the backyard, LPA observed several dozen cigarette buds on the ground, adjacent to bedroom #4 and the family room exit to the back yard. LPA also observed a fallen tree foliage on the backyard ground as well. LPA noted additional tree foliage on the side of the home, adjacent to bedrooms 2 & 3. While touring the hallway bathroom adjacent to bedroom #3, LPA observed a container of lysol toilet cleaner in the cabinet below the sink. LPA also observed the shower in bedroom #3 had a stained non slip bath mat and the lower sections of the shower had grime, that was slightly orange in color. LPA also observed the air extractor in the hall way bathroom had lint. LPA toured the facility garage. Note the laundry area and garage do were not locked. During the visit, residents were using the garage/laundry area as a exit. While touring the garage, LPA observed the following items, accessible: Sevin insect Killer and lighter fuel. Page 1 Out of 3.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 11

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/27/2026

NARRATIVE

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Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured at 112 degrees F in resident bathrooms.

While touring the kitchen area, LPA requested to see the knives storage area. LPA observed it was locked, but noted if you pull the cabinet, it creates an opening, with enough room to stick a hand inside the knife storage area.

While touring the area between room 1 and Room 2, LPA observed cabinets. LPA observed the cabinet had a lock. LPA engaged the unlocking button mechanism, and the lock, unlocked. Inside the cabinet was a container of cleaning powder detergent.

Fire extinguisher was serviced in April 17, 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by staff, and were functional. LPA observed facility first aid kit. LPA requested to review the facility emergency drill log. LPA was not provided documentation showing drills have taken place.

LPA reviewed facility records for 3 staff. LPA requested to review staff S1's health screening. S1 stated he/she did not have it and was going to get one. LPA requested to review staff S1-S3's training records. LPA was provided a sheet with 1 training, for April 1, regarding medication training, for staff S1 and S2.

LPA reviewed 6 resident records. Resident R4's physician's report dated June 6, 2025 states, this resident is at risk if allowed direct access to personal grooming and hygiene items. During a review of residents files 4 (R1, R2, R5, R6) Out of 6 residents are under the age of 60. The facility has a census of 6 and the facility did not request an exception request for the residents who are under the age of 60 years.

LPA also noted R3 did not have a personal property log. R5 had a personal property log that was blank. (Note, LPA was informed by S1 that R5 had just purchased new electronic products.) R6 has a personal property log from his/her previous form, but does not have one for this facility, dated from his/her move in.

Page 2 Out of 3.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

Page: 3 of 11

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/27/2026

NARRATIVE

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LPA reviewed 3 resident medications and centrally stored medication records. Staff S1 stated they did not have a centrally stored medication record for R2's medications. R3 had medications that were also not listed on the centrally stored medication record.

while reviewing R2's medications, S1 informed LPA that the facility has Tums and Tylenol medications that they use for all the residents in the home. LPA asked S1 if all the residents have a prescription for the Tums and tylenol. S1 stated the facility does not have a prescription.

While reviewing R2's and R6's medications, LPA observe both medication containers had several loose medications not inside their original container.

During the course of this annual inspection, LPA took photographic evidence documenting the deficiencies that were observed.

Deficiencies are being cited during today's visit, see LIC809-D. This report was reviewed with Administrator Amritpal Kaur Powar and a copy of the signed report was provided. Appeal rights were provided.

Page 3 Out of 3. END OF REPORT.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

Page: 4 of 11

Document Has Been Signed on 02/27/2026 04:35 PM - It Cannot Be Edited

Created By: Manuel Monter On 02/27/2026 at 03:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. During the course of the inspection, LPA noted multiple instances where cleaning products, were acessilbe to residents in care. LPA also noted insect killer and lighter fluid acessible in the garage. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2026
	Plan of Correction
1 2 3 4	ADM stated he will send a plan of action on how he will ensure disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended. ADM stated he will send to LPA by POC due date.

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. While reviewing R2's and R6's medications, LPA observe both medication containers had several loose medications not inside their original container. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2026
	Plan of Correction
1 2 3 4	ADM stated he will send a plan of action on how he will ensure Each resident's medication shall be stored in its originally received container. ADM stated he will send the plan of correction to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

Page: 5 of 11

Document Has Been Signed on 02/27/2026 04:35 PM - It Cannot Be Edited

Created By: Manuel Monter On 02/27/2026 at 03:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and records reviewed, the licensee did not comply with the section cited above. while reviewing R2's medications, S1 informed LPA that the facility has Tums and Tylenol medications that they use for all the residents in the home. LPA asked S1 if all the residents have a prescription for the Tums and tylenol. S1 stated the facility does not have a prescription. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2026
	Plan of Correction
1 2 3 4	ADM stated he will send a plan of action on how he will ensure every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

Page: 6 of 11

Document Has Been Signed on 02/27/2026 04:35 PM - It Cannot Be Edited

Created By: Manuel Monter On 02/27/2026 at 03:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA noted cigarettes scattered on the floor in the backyard. LPA also noted tree foileage on the ground. LPA also noted stains in the hallway bathroom. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2026
	Plan of Correction
1 2 3 4	ADM stated he will send a plan of action on how he will ensure the facility will remain clean, safe, sanitary and in good repair at all times. ADM stated he will send his plan to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

Page: 7 of 11

Document Has Been Signed on 02/27/2026 04:35 PM - It Cannot Be Edited

Created By: Manuel Monter On 02/27/2026 at 03:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to review staff S1's health screening. S1 stated he/she did not have it and was going to get one. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2026
	Plan of Correction
1 2 3 4	ADM stated staff S1 will get a new health screening and send LPA documenation showing S1 has completed his/her health screening by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

Page: 8 of 11

Document Has Been Signed on 02/27/2026 04:35 PM - It Cannot Be Edited

Created By: Manuel Monter On 02/27/2026 at 03:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

Personnel Records

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. LPA requested to review staff S1-S3's training records. LPA was provided a sheet with 1 training, for April 1, regarding medication training, for staff S1 and S2. This which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2026
	Plan of Correction
1 2 3 4	ADM stated he will send a letter of understanding regarding the reguation. ADM stated he will send documenation showing S1-S3's training to LPA by POC due date.

Type B

Section Cited

CCR

87506(b)(16)

Resident Records

(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA also noted R3 did not have a personal property log. R5 had a personal property log that was blank. R6 has a personal property log from his/her previous form, but does not have one for this facility, dated from his/her move in. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2026
	Plan of Correction
1 2 3 4	ADM stated he will create a new personal property log for R3, R5 and R6. ADM stated he will send a copy to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

Page: 9 of 11

Document Has Been Signed on 02/27/2026 04:35 PM - It Cannot Be Edited

Created By: Manuel Monter On 02/27/2026 at 03:21 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. LPA requested to review the facility emergency drill log. LPA was not provided documentation showing drills have taken place. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2026
	Plan of Correction
1 2 3 4	ADM stated he will conduct a drill and send documenation showing a drill has taken place. ADM stated he will send a letter of understanding regarding the regulation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

Page: 10 of 11

Document Has Been Signed on 02/27/2026 04:35 PM - It Cannot Be Edited

Created By: Manuel Monter On 02/27/2026 at 03:24 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)

87465 Incidental Medical and Dental Care (h) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Resident R2 and R3 had medications that were not listed on the centrally stored medicatoin record. S1 stated R2 does not have his/her medications listed on the centrally stored medication record. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2026
	Plan of Correction
1 2 3 4	ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send a copy of the updated centrally stored medicaton records for Rw and R3 to LPA by POC due date.

Type B

Section Cited

CCR

87455(b)(8)

87455 Acceptance and Retention Limitations (b)(8) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review)], the licensee did not comply with the section cited above. During a review of residents files 4 (R1, R2, R5, R6) Out of 6 residents are under the age of 60. The facility has a census of 6 and the facility did not request an exception request for the residents who are under the age of 60 years. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2026
	Plan of Correction
1 2 3 4	ADM stated he will send an age exception request for at least 3 residents under the age of 60. ADM stated he will send the plan of correction to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2026

LIC809 (FAS) - (06/04)

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