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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320308
Report Date: 10/05/2023
Date Signed: 10/05/2023 09:31:37 PM


Document Has Been Signed on 10/05/2023 09:31 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:STERLING SENIOR LIVING 3FACILITY NUMBER:
198320308
ADMINISTRATOR:NAREZ, ALBERTO P.FACILITY TYPE:
740
ADDRESS:23025 NICOLLE AVENUETELEPHONE:
(424) 477-5657
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:6CENSUS: 6DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Kian Pascual & Albert NarezTIME COMPLETED:
04:28 PM
NARRATIVE
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On 10/05/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Kian Pascual and Albert Narez. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (6) elderly residents. (2) ambulatory, (3) non-ambulatory and (1) bedridden. The facility is approved for (4) hospice residents. Currently, there is only (1) hospice in care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) resident bedrooms (2) common bathrooms, an activity room, a dining area, a kitchen, a patio, and a garage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 109.6 degrees F. A comfortable temperature was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was maintained in place. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed First Aid Kit was maintained. A working landline phone was operational.

Evaluation Report continues LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 09:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: STERLING SENIOR LIVING 3
FACILITY NUMBER: 198320308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited. A bottle of wound solution was found under bathroom #2 sink accessible to resident with dementia. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Licensee will ensure that all hazardous and toxic materials are kept out of reach and unaccessible to residents in care. These materials must be stored in locked storage. Proof of correction must be sent sent by 10/06/23.

(Corrected during visit 10/05/23)
Type A
Section Cited
CCR
87309(b)
Storage Space
(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above. LPA identified prescribed medications that required refrigeration were store in refrigerator for residents. The medications were accessible to residents in care. This violaton which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Licensee will ensure that all prescribed medications for residents that required refrigeration, must be store properly and locked compartment. Proof of correction must be sent sent by 10/06/23.

(Corrected during visit on 10/05/23)
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 09:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: STERLING SENIOR LIVING 3
FACILITY NUMBER: 198320308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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Based on observation, the licensee did not comply with the section cited above. LPA identified window blinds in room #3 with broken blinds and room #5 bedside table as a missing drawer. The violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee will ensure the facility is maintained in good repair at all times. Broken blinds must be replaced and bedside end table will be replaced with working drawers. Proof of correction must be sent to LPA by due date: 10/26/23 via email.ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87415(a)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. The facility does not have a NOC shift staff according to LIC 500 and administrator. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee will ensure to provide a night supervision for all residents during NOC shift. The staff must be familiar with planned emergency procedures, and shall be be fully trained. Proof of correction a submission of an updated LIC 500 must be sent by POC due date: 10/26/23 to LPA via email: ernand.dabuet@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 09:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: STERLING SENIOR LIVING 3
FACILITY NUMBER: 198320308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified no record keeping records were foun for resident # 4 on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee will ensure that all residents must have medication recordkeeping on records (Medication Administration Record) MAR for CCLD to audit. Licensee will obtain a copy of documentation noting medications were disbursed properly per PCP orders. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/26/23.
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and review, the licensee did not comply with the section cited above. LPA identified in resident #2, #3, and #5 PRNs and prescibed medications by PCP were not included on the Medication Administration Record (MAR). This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee shall ensure medications are administered according to PCP orders with proof of documentation. Licensee will obtain a copy of documentation noting medications were disbursed properly per PCP orders. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/26/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 09:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: STERLING SENIOR LIVING 3
FACILITY NUMBER: 198320308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

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
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Based on record review and interview, the licensee did not comply with the section cited above. LPA was informed by staff that no emergency drills have been conducted. The facility did not have log drills have been performed. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee shall ensure that emergency drills are conducted from quarter to quarter and that is documentated when it was conducted and participates of staff and residents. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/26/23.
Type B
Section Cited
CCR
87608(5)(B)
87608 Postural Supports (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above. LPA identified resident #3 had full bed rails and not on hospice care with no dotor's orders. This violationwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee will ensure to that bedrails are permitted with hospice residents and that any resident requiring full bedrails must accompany doctor's orders. Proof of correction must be sent to LPA by POC due date: 10/26/23 via email: ernand.dabuet@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 09:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: STERLING SENIOR LIVING 3
FACILITY NUMBER: 198320308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(5)
87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified resident #4 did have a current medical/appraisal assessment and is diagnosed with Dementia. The last medical assessment is 2021. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee with adhere to Title 22 Sec 87705 and ensure that all residents with Dementia receives medical/appraisals annually. Proof of correction must be sent to LPA by due date; 10/26/23 via email: ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General - All RCFE staff...shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA identified staff #1 and #5 did not a valid or current CPR/First Aid on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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The licensee is to obtain current first aid certificates for staff #1 and #5 will create a plan to ensure that ensure that caregiver staff who assist residents with personal activities of daily living receive annual first aid training. Proof of correction will be submitted to CCL via email at ernand.dabuet@dss.ca.gov by 10/26/23. The licensee may ask for an extension if more time is needed via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 09:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: STERLING SENIOR LIVING 3
FACILITY NUMBER: 198320308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87407(d)
87407 Administrator Recertification Requirements (d) To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department’s Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified staff #1 did not have a current administratior certificate. The certificate expired 08/30/23 and not proof of evidence that renewal was submitted to Department Administrator Certification. This violaton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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Licensee will show proof of a renewal for administator's certificaiton was sent by mail. Proof of correction will be submitted to CCL via email at ernand.dabuet@dss.ca.gov. by due date: 10/26/23.The administrator may ask for an extension if more time is needed via email.
Type B
Section Cited
CCR
87405(b)(2)
87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2 )Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record reviews the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited. Administrator is not meeting the required hours for supervision at the facility according to staff. The admnistrator spend less than 20 hour per week. This which poses a potential health and safety risk to residents in care.
POC Due Date: 10/26/2023
Plan of Correction
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The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. The plan will included the required hours of 20 hours spent for operation and supervison at the facility. Plan of correction will be submitted by POC due date: 10/26/23 via emal: ernand.dabuet@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STERLING SENIOR LIVING 3
FACILITY NUMBER: 198320308
VISIT DATE: 10/05/2023
NARRATIVE
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LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

An audit of resident #1-#6 (R1-R6) service files and staff #1-#7 (S1-S7) personnel files were conducted.

DEFICIENCIES:
  • Postural Support: non-authorized full bed rails for resident #3 – Type B
  • Disinfectants/Toxic Cleaning Solutions: unsecured/unlocked bathroom #2 cabinet – Type A
  • Room #3 window blinds: Broken shades – Type B
  • Room #4 End Table missing drawer – Type B
  • Administrators Certificate: Expired for Staff #1 – Type B
  • No current CPR/First Aid certificates - staff #1 and #5 - Type B
  • Resident 4: No current medical and appraisal assessment for resident with Dementia – Type B
  • Medicines required refrigeration not stored properly - Type A
  • No night supervision - No night shift staff after 8pm - Type B
  • No quarterly emergency drills conducted/documented - Type B
  • No documentation/record keeping of PRN for resident #4 - Type B
  • Prescribed medications and PRN not included in (MAR) - Type B
  • Administrator's Qualification: Failed to conform to applicable rules and regulations, which resulted to multiple citations. - Type B

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Albert Nanrez and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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