Five Star Senior Living

Type of visit: POC

Licensing Program Analyst Manuel Monter conducted a POC case management visit to clear deficiencies cited on February 27, 2026 and discuss pending age exceptions. LPA met with Administrator Amritpal Kaur Powar and explained the purpose of the visit. Plan of Corrections The facility cited the following Type A deficiencies on February 27, 2026: 87309 Storage Space and Access (a), POC due date February 28, 2026. 87465 Incidental Medical and Dental Care Services (h)(5), POC due date February 28, 2026. 87465 Incidental Medical and Dental Care Services (e), POC due date February 28, 2026 The Facility cited the following Type B deficiencies on February 27, 2026 87303 Maintenance and Operation (a), POC due date March 6, 2026 87411 Personnel Requirements - General (f), POC due date March 6, 2026 87412 Personnel Records (c), POC due date March 6, 2026 87506 Resident Records (b)(16), POC due date March 6, 2026 HSC 1569.695(c), POC due date March 6, 2026 87465 Incidental Medical and Dental Care (h) (6), POC due date March 6, 2026 87455 Acceptance and Retention Limitations (b)(8), POC due date March 6, 2026 LPA received plan of corrections for type A and Type B deficiencies by POC due dates. Deficiencies cleared during todays visit. POC cleared letter provided to ADM. Age Exception Requests During Today’s Visit, LPA discussed with Administrator Amritpal Kaur Powar the current Age Exception Requests. No deficiency was cited during todays visit. This report was reviewed with Administrator Amritpal Kaur Powar. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Required - 1 Year

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. 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. 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.the state’s words, verbatim · CDSS document, Feb 27, 2026

Allegation investigated: Resident sustained unexplained injuries while in care

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 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 REPORTthe state’s words, verbatim · CDSS document, Sep 12, 2025 · control 26-AS-20250506085944

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Racheal Mosely. The purpose of the visit was to amend reports that were originally delivered to the facility on 05/28/2025 and 08/22/2025. The report from 05/28/2025 was part of a complaint investigation that the department received on 05/12/2025. The report from 08/22/2025 was part of a complaint investigation that the department received on 05/06/2025. During the investigations, LPA Marrufo reviewed the Appraisal/Needs and Services Plan for resident R1. LPA Marrufo observed that R1's Appraisal/Needs and Services Plan was not written with needs and objectives that are measurable and verifiable. An advisory note was issued. See LIC9102 Advisory Note for more information. LPA Marrufo advises facility Administrator to review the information about the Department’s Technical Support Program (TSP) found at the Community Care Licensing Division (CCLD) website: www.cdss.ca.gov. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Racheal Mosely and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 12, 2025

Allegation investigated: Staff yelled at a resident while in care

**Amended on 09/12/2025 to change the allegation finding from Substantiated to Unsubstantiated.**Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit. On 05/06/2025, the department received a complaint with the above allegation. On 05/15/2025, LPA Marrufo conducted an initial complaint investigation visit. LPA Marrufo met today with Racheal Mosly. During interview on 05/15/2025, resident R1 stated Administrator (ADM) Jesse Powar yelled at R1 while R1 was speaking on the phone with a family member. During interview on 05/15/2025, ADM stated to have observed R1 to be wobbling and asked R1 where his/her walker was. ADM stated to have not yelled at R1. ADM stated to have a heavy tone of voice, which can sometimes sound like yelling. R1 stated to have not been aware on the day of the incident that R1 was on the phone when ADM asked R1 where his/her walker was. See LIC9099-C page for more information. Page 1 of 2. Unsubstantiated **Amended on 09/12/2025 to change the allegation finding from Substantiated to Unsubstantiated and added interview from staff S1 conducted on 09/12/2025.** During interview on 08/22/2025, witness W1 stated to have been speaking on the telephone with R1 when W1 heard ADM yell at R1 in a scolding tone to use his/her walker. W1 stated to have later spoken on the telephone with ADM, and ADM apologized to W1 for yelling at R1. During interview on 09/12/2025, staff S1 stated that ADM's voice is calm and is not normally loud. S1 stated ADM's voice is not misinterpreted as yelling when it is not. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22 This report was reviewed with Racheal Mosly and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT **Amended on 09/12/2025 to remove the allegation "Resident sustained unexplained injuries while in care" and the accompanying narrative for that allegation.** Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22 This report was reviewed with Racheal Mosly and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 26-AS-20250506085944

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 23, 2025

**This LIC9099-D page is amended to remove the deficiency issued on 08/22/2025. The allegation finding was amended to be changed from Substantiated to Unsubstantiated.**the state’s words, verbatim · CDSS document, Aug 22, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Racheal Mosly. The purpose of the visit was to follow up with the facility for failing to report two incidents in which resident R1 was taken to the hospital. 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 form 05/07/2025 states the issue addressed during the visit was "multiple open wounds." However, there are no incident reports sent from the facility for those two hospital visits. An Advisory Note was issued. See LIC9102 page for more information. This report was reviewed with Racheal Mosly and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 22, 2025

Allegation investigated: 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

**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 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. 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. **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 REPORTthe state’s words, verbatim · CDSS document, May 28, 2025 · control 26-AS-20250512144930

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with staff Esha Dhiman (S1). LPA observed 5 residents and 2 staff in the facility. The purpose of today's visit is to follow up with the case management conducted on 3/13/2025. LPA toured the facility with S1. Dish washing solution bottle was observed above the sink in the kitchen. Staff removed it and locked it immediately. LPA checked staff files and residents files. LPA observed some documents are not maintained up to date. S1 stated Administrator (ADM) might maintain documents at his/her site. LPA talked to ADM on the phone. ADM stated he/she will send the documents to LPA via email. ADM stated some residents are already scheduled to have doctor visit. Exit interview was conducted with S1. S1 stated he/she will make sure ADM to send updated documents to LPA. The report was provide to S1 for review and signature. A copy of the report was provided to S1.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with Administrator (ADM) Jasvir Powar. LPA observed 2 staff in the facility and 5 residents in the facility. LPA reviewed 3 residents files and 3 staff files. LPA toured the facility inside out with ADM. License, Personal Rights posters, and administrator certificate were observed at the entrance. LPA inspected living room, family room, kitchen, dinning room, 1 staff live-in room, 1 office, and laundry room. Medication closet was observed locked. LPA observed the knives closet unlocked. HM locked the knives closet immediately. Dish soap closet solution closet was observed unlocked. HM locked the closet immediately. There are 3 rooms for residents, and 2 bathrooms are in facility. Room temperature was observed at 70 degree F, and hot water temperature was observed at 119 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient. The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the carbon monoxide detectors, and they were working fine. First aid box, flash light were observed in the facility. LPA inspected the backyard, there wee 2 pots of plants blocked one of the exit. ADM removed the 2 pots of plants before LPA finished the inspection. ADM stated the last drill was conducted on 1/3/2025. ADM stated the facility did not log the date for the last Drill. Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.the state’s words, verbatim · CDSS document, Mar 13, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility staff pushed a resident. Facility staff does not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with staff Laura Ochoa (LO). On 12/28/2023, the Department received a complaint with the allegations that facility staff pushed a resident and facility staff does not treat resident with dignity and respect. On 1/3/2024, the Department conducted an initial investigation visit. LPA interviewed ADM, 1 staff and 4 residents. LPA resident roster, LIC500, resident physician report, appraisal Needs and Service plan, food menu, Admission Agreement, and Medication Administration Records.. Continue on LIC9099-C. Page 1 of 3. Unsubstantiated Facility staff pushed a resident: Facility staff does not treat resident with dignity and respect: The allegations are that facility staff S1 pushed a resident R1 and yelled at the resident R1. On 1/3/2024, LPA interviewed Administrator Jasvir Powar (ADM). ADM stated he/she did not receive any report from staff or residents regarding staff abused residents. ADM stated he/she received a phone call from a resident's family member (FM) complaining about staff abused a resident. ADM stated the facility has camera surveillance system facing outside of the building, facing living room, family room, hall way. the exit door and facing the medication cabinet. ADM stated he/she conducted an internal investigation. ADM stated he/she traced the footage of the camera surveillance system and did not find any staff abusing residents. ADM stated he/she interviewed other residents and staff and did not find anything. ADM stated staff S1 denied the allegations. ADM stated S1 is a quick responder and talks louder. ADM stated he instructed S1 to talk in soft and to behave polite to vulnerable people. LPA interviewed staff S1. S1 denied the allegations. LPA interviewed resident R1. R1 stated no staff pushed or yelled at him/her. R1 stated he/she complained the facility staff to his/her family member before. R1 stated the facility staff treat him/her good. LPA interviewed 4 other residents (R2 - R5). 4 out of 4 residents stated they did not see or hear any staff pushed or yelled at residents. Based on the interviews, there is no evidence to indicate staff S1 pushed or yelled at resident R1. Based on documents reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted for today’s visit. Exit interview was conducted with staff LO. A copy of this report was provided to LO. Page 2 of 2. Facility did not provide a resident with over-the-counter medication when requested: The allegation is that the facility did not provide a resident R1 with over the counter medication M1 when resident R1 requested. On 1/3/2024, LPA interviewed ADM. ADM stated the facility staff administer medications to residents based on doctor's order or prescriptions. ADM stated R1's family member (FM) sent over the counter medication M1 to the facility and asked the facility to administer the medication M1 to R1. ADM stated the facility cannot administer medications to residents without doctor's order, even the over the counter medications. ADM stated the facility provide R1's over the counter medications M1 to R1's doctor to approve. ADM stated R1's doctor approved the over the counter medications M1 to administer to R1. LPA interviewed R1. R1 stated the staff did administer the medication M1 to him/her. Based on the interviews, the facility staff administer the over the counter medication M1 to R1 after R1's doctor approved the medication M1. The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with staff LO. This report was provided to review and for signature. A copy of this report was provided to LO. Page 2 of 2. Facility does not follow resident's special diet: The allegation is that the facility does not follow resident R1's special diet. On 1/3/2024, LPA interviewed Administrator (ADM). ADM stated the facility did not receive R1's doctor's order for special diet. ADM stated if residents have special medical condition, the facility will call 911 or contact the residents' case managers. Based on the review of R1's physician report dated 6/29/2023, R1 has special diet for Lactose Intolerant, Crohn's, and dental soft diet. Lactose Intolerance should avoid Milk, Cheese, Ice Cream, Bread, Ketchup, mustard, Mayo, and chocolate. Crohn's diet should eat smaller meals more frequently, stay hydrated and drink at least eight cups of fluids per day, and avoid foods that may increase stool output,. Dental soft diet should consists of foods that are easy to chew and swallow to reduce the need for chewing. ADM stated the facility did not receive R1's physician order for R1's special diet and claimed R1 does not have special diet. The facility Administrator and staff do not know R1 has special diet and did not follow R1's special diet Based on the interviews and records reviewed, the facility does not know R1 has special diet to follow and did not provide food to R1 based on R1's special diet. The Department has investigated the above allegations. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Citations were noted today. Please see LIC9099-D. Appeal right was provided. Exit interview was conducted with staff LO. A copy of the report was provide to LO. Page 2 of 2.the state’s words, verbatim · CDSS document, Oct 18, 2024 · control 26-AS-20231228133948

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Oct 25, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirements was not met as evidenced by: Based on the interviews and record reviews, the facility did not provide the special diet prescribed by resident R1's physician, this poses a potential health, safety or personal rights risk to a person in care.the state’s words, verbatim · CDSS document, Oct 18, 2024

Plan of correction: Administrator stated to submit a plan of correction by the POC due date to ensure the facility follows residers' doctors prescribed special diets.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an annual inspection visit, and met with Administrator (ADM) Jasvir Powar. LPA observed 1 staff in the facility and 6 residents in the facility. LPA reviewed 3 residents files and 3 staff files. LPA toured the facility inside out with ADM. Licensee, and administrator certificate were observed at the entrance. LPA inspected living room, family room, kitchen, dinning room, 1 staff live-in room, 1 office, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked. There are 3 rooms for residents, and 2 bathrooms are in facility. Non skid mats were observed in the bathroom. Room temperature was observed at 70 degree F, and hot water temperature was observed at 119 degree F. 2 days perishable food supplies and 7 days non perishable food supplies were observed sufficient. The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the fire alarm, and smoke and carbon monoxide detectors, and they were working fine. First aid box, flash light were observed in the facility. LPA inspected the backyard, there was no obstruction to block the walkway. LPA checked the log for fire and emergency drill, the last drill was conducted on 1/25/2024. Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.the state’s words, verbatim · CDSS document, Mar 11, 2024