Five Star Care Home II

Type of visit: Case Management - Other

On September 23, 2026, Licensing Program Analyst (LPA) conducted an unannounced visit for facility closure. Upon arrival, LPA observed the garage door was opened with construction in progress at the facility. LPA went to the front door, and met with one of the construction workers who stated that the owner was getting ready to sell the property and they were there to install new flooring. They also stated that everyone has moved out about two weeks ago. LPA toured the facility and observed the kitchen, living room, dinning room, bedrooms, outdoor and garage were empty. LPA did not observe evidence of care and supervision of residents. After the tour of the facility, LPA called and left a message for the administrator/licensee regarding the visit. On September 24, 2026, administrator/licensee, Evelina Melkanya returned call and LPA discussed the facility closure visit that was conducted yesterday. CCLD will be proceeding with the closure as the licensee is no longer interested in maintaining a license. A forfeiture letter will be sent to licensee and the facility number 415600705 shall be closed. This report is reviewed, and discussed with the administrator/Licensee over the phone, and a copy is provided electronically.the state’s words, verbatim · CDSS document, Sep 24, 2026

Type of visit: Required - 1 Year

On June 11, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Irma Perez and LPA explained the purpose of the visit. The administrator was notified by phone of LPA's visit. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. A tour of resident's room was conducted and observed to have sufficient furniture and furnishings. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 111 degrees Fahrenheit. Fire extinguishers were checked. A review of (4) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. During the facility tour with caregiver, LPA and caregiver observed the screen sliding door in one of the private rooms has 2 holes on it. During the inspection, LPA observed some records were not available for inspection such as the emergency drills, and staff education/training resulting in the caregiver contacting the administrator who sent the missing documents to LPA via email. The following documents were requested to be submitted to CCL by 6/18/2026 - Liability Insurance, Administrator Certification, and staff education records 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 civil penalties. This report is reviewed and discussed with the caregiver. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 11, 2026

Type of visit: POC

On 7/11/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced plan of correction visit to follow on a civil penalty that was assessed on 7/3/2025. LPA met with the caregiver, Irma Perez and explained the purpose of today's visit. On 7/3/2025, LPA conducted an unannounced Plan of Correction visit to follow up on the citations that were issued during the annual visit on 6/17/2025. During the visit, LPA observed these deficiencies were not corrected:1569.625(b)(2)Other Provisions, 1569.695(c) Other Provisions, 87608(a)(3) Postural Supports, therefore, a civil penalty in the amount of $3300 was assessed from 6/18/2025 - 6/28/2025. During today's visit, LPA observed the above citations were corrected and civil penalty has been stopped on 6/29/2025. In addition, LPA also observed the citation that was cited on 7/3/2025 87355(a) Criminal Background Clearance has been corrected. This report is reviewed and discussed with caregiver; A copy is provided.the state’s words, verbatim · CDSS document, Jul 11, 2025

Type of visit: POC

On July 3, 2025, Licensing Program Analyst (LPA) Murial Han conducted a plan of correction visit for the annual inspection that was conducted on June 17, 2025. LPA met with caregiver, Irma Perez and explained the purpose of today's visit. The administrator arrived and assisted with the visit. During today's visit, LPA toured the common areas, garage, bath/shower room, dining room, living room, resident room, etc., reviewed plan of correction documents that were submitted by the administrator: The following deficiencies , which were cited on 4/1/2025 are corrected: - 87303(e)(2) Maintenance and Operation - 1569.618(c)(3) Other Provisions - 87465(c)(3) Incidental Medical and Dental Care Services - 87456(a)(2) Evaluation of Suitability for Admission - 87618(b)(3)(B) Oxygen Administration - Gas and Liquid - 87633(a)(1) Hospice Care for Terminally Ill Residents - 87303(a) Maintenance and Operation -1569.696(a) Other Provisions - 87618(b)(3)(A) Oxygen Administration - Gas and Liquid The following deficiencies are not corrected: - 1569.625(b)(2) Other Provisions -1569.695(c) Other Provisions -87608(a)(3) Postural Supports During today's visit, LPA observed staff #1 (S1) did not have a completed Criminal Record Clearance. According to S1, S1 started working at the facility since 7/1/2025 and the administrator stated that S1 was a reliever and was being trained at the facility. Due to the above observation and deficiency not being corrected, a civil penalty is being assessed in the amount of $100 a day from 6/18/2025 through 6/28/2025 and will continue to accrue until corrected. A total civil penalty of $3500 ( $3300 and $200 for incomplete criminal background clearance for S1) is being assessed. 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 and caregiver. A copy of this report and the appeal rights were providedthe state’s words, verbatim · CDSS document, Jul 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(a) · Plan of correction due date: Jul 4, 2025

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve..or employment, .. Based on observation, interview and record review, LPA observed S1 caring for resident but criminal record clearance was incomplete which poses an immediate health and safety risks for residents in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: The administrator will develop a plan to ensure all staff have a completed the criminal record clearance process prior to working. The administrator will provide a copy of the plan of correction to CCL by 7/4/2025.

Type of visit: Required - 1 Year

On June 17, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Irma Perez and LPA explained the purpose of the visit. The administrator was notified by phone of LPA's visit. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. A tour of resident's room was conducted and observed to have sufficient furniture and furnishings. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 138-143 degrees Fahrenheit. Fire extinguishers were checked. During the tour, LPA observed strong urine odor in resident rooms, a layer of black dust on top of the kitchen vent, dirty floor edges in the kitchen and around the facility, resident rooms were cluttered, etc. A review of (5) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. The following documents were requested submitted to CCL by 6/19/2025 - LIC 500, Liability Insurance, Administrator Certification A civil penalty of $ 1,250.00 is being assessed today for 5 repeat violations that were cited during the annual visit on June 17, 2024. 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 caregiver. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 17, 2025

Type of visit: Required - 1 Year

On June 17, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Irma Perez and LPA explained the purpose of the visit. The administrator, Evelina Melkanyan arrived shortly thereafter. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. LPA observed a bed was blocking the outdoor passageway. A tour of resident's room was conducted and observed to have sufficient furniture and furnishings. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 106-115 degrees Fahrenheit. Fire extinguishers were checked. A review of (6) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. The following documents were requested submitted to CCL by 6/24/24: - LIC 500, Liability Insurance, Administrator Certification 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 civil penalties. . This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 17, 2024