Five Star Care Home

Type of visit: Required - 1 Year

On 7/30/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Lorna Torres, Caregiver and explained the purpose of the visit. Evelina Melkonyan, Administrator/Licensee arrived later during the visit. LPA toured the physical plant. This is a 1-story building with 6 bedrooms, 6 bathrooms, a kitchen, living room, dining room, and front and backyards. All bedrooms had the required furniture and sufficient lighting. All bathrooms had anti-skid flooring and grab bars. The facility's smoke alarms and carbon monoxide detectors were observed to be in working order. No accessible bodies of water or hazards were observed. The facility's fire extinguisher was last checked on 3/23/2026 and was observed to be fully charged. The facility's hot water temperature was measured within 105-120 degrees Fahrenheit. The facility had the required 7 days of non perishables and 2 days of perishables. No food was expired. The facility's first aid kit had the required items. All sharp objects, soap, detergents, and poisons were observed to be locked and in-accessible to persons in care. LPA reviewed 5 resident files and 3 staff files. All were observed to be complete. During record review, LPA observed that Licensee did not have documentation of Quarterly Emergency drills for 2026. A Technical Violation was provided. In addition, LPA observed that Licensee did not have documentation of 8 hours of Dementia training and 4 hours of training on the subjects of postural supports, restricted and prohibited health conditions, and Hospice care. Technical violations were provided. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility. No deficiencies were cited during today's visit. An exit interview was conducted. A copy of this report was provided to the facility representative.the state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Required - 1 Year

On July 18, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Caregiver, Rolly Bautista and explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility. There are six resident bedrooms and one staff bedroom. All resident rooms were observed to be clean and odor-free with half bathrooms. LPA observed two full bathrooms equipped with grab bars, non-skid mats, and in good repair. Water temperature throughout the facility measured between 107-110 degrees F. Extra linen was observed to be present. First aid kit was observed to be complete. Dining room was observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed seven day non-perishables but not two day perishables. Medications, sharps, and chemicals were observed unlocked an accessible to residents in care. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of March 2025. Emergency drills are being conducted every three month. LPA reviewed 5 resident records and 5 staff records. Medication review was done and all medications are accounted for. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in additional civil penalties. This report is reviewed and discussed with the Administrator. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 18, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 06/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with caregiver Lorna Torres and explained the purpose of today's visit. There is 1 staff present and 6 residents present. 5 of the residents are still in bed but one is awake and interacting freely in the facility. A second caregiver is on duty as well but is picking up resident medications per Lorna. LPA was allowed entry into the facility. This is a single level facility. Annual fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer adjacent to the stove top. Medications are also locked in the kitchen in a cabinet. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed that there is one fire extinguisher in place in the dining room last inspected 03/28/2024, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located in the garage area. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 107F. Shower floor uses non-skid mat when shower is in use. LPA observed all residents rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place. Continued on next page... Page 2 LPA reviewed 3 client files and also reviewed 3 staff files on this day. Per resident files reviewed they are incomplete and not current. Needs and appraisal plans are not completed as well as other items such as current physician reports as several are from when the resident was admitted to the facility. Per staff files reviewed, staff do not have current first aid cards on file. These discoveries pose a potential health and safety risk and a citation is issued. P&I is not handled by the facility. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as expired on 12/23/2022 but has submitted the renewal but has not received the new license per licensee phone call made during today's visit. The following updated forms are requested to be submitted to CCLD by 06/24/2024: • Copy of updated Administrator Certificate • LIC308 Designation of responsible staff person • LIC400 Affidavit Regarding Client/Resident Cash Resources • LIC610D Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property such as lease agreement with expiration date Citations issued on attached LIC809D. Report is reviewed with caregiver Lorna and a copy is provided.the state’s words, verbatim · CDSS document, Jun 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jun 24, 2024

87506 Resident Records:(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This regulation has not been met as evidenced by: Based on resident records reveiwed, 3 resident files are not current. Needs and appraisal plans are not completed as well as other items such as current physician reports as several are from when the resident was admitted to the facility. This can pose a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: The licensee shall develop a plan in writing on how she will correct this citation to maintain current records for all residents at all times. POC due by 06/24/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR80075(f) · Plan of correction due date: Jun 24, 2024

80075(f) Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This regulation has not been met as evidenced by: Based on faciltiy staff files reviewed, 3 of 3 staff files indicate that first aid cards expired on 05/2024. This can pose a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: The licensee shall submit proof that all staff, including the licensee, will receive current first aid training and provide copies of first aid cards as part of the correction. POC due by 06/24/2024