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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602239
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:44:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20231211140253
FACILITY NAME:STERLING SENIOR LIVINGFACILITY NUMBER:
198602239
ADMINISTRATOR:KELLOGG, MICHELLEFACILITY TYPE:
740
ADDRESS:2210 W 234TH STREETTELEPHONE:
(310) 325-2275
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 6DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Ricardo BernalTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility failed to maintain complete and accurate resident records.
INVESTIGATION FINDINGS:
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On 12/12/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit at the facility listed above. LPA met with House Manager, Ricardo “Rickey” Bernal, and explained the purpose of today’s visit.
During today’s visit LPA conducted a facility inspection, interviewed Staff (S1-S2) , interviewed Residents (R1-R6), and received documents pertinent to the investigation. The following documents were received and reviewed. Resident Roster, Centrally Stored Medications, Medication Administration Record (MAR), Admission Agreement, Physicians Report, Resident Appraisal, Needs and Service Plan, Safeguard for Property/Valuables.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 11-AS-20231211140253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239
VISIT DATE: 12/12/2023
NARRATIVE
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The investigation revealed the following:

Allegation: Facility failed to maintain a complete and accurate resident’s records.

The allegation alleges that the facility has incomplete resident records.

During the facility file review LPA reviewed and received copies of required documents to maintain for Residents. LPA reviewed six (6) Resident files, three (3) out of the six (6) Resident files had the required documents. During file review LPA observed the following documents were missing: Resident R2 was missing the Appraisal, Needs and Service Plan, and Safeguard for Property/Valuables. Resident R3 was missing the Appraisal, Needs and Service Plan, TB test, and Safeguard of Property/Valuables. Resident R4 was missing a Physicians Report and TB test. Interviews with Staff S1 and S2, two out of two stated they do not handle the Residents files, that the Administrator is responsible for making sure they have the required documents.

Based on LPAs observations and record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number8), are being cited on the attached LIC 9099D.



An exit interview was conducted with House Manager, Rickey Bernal, and a copy of this report and the Appeal Rights were provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20231211140253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
87506(b)(10)
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87506 Resident Records (b)each resident record shall contain at least the following information (10)reports of medical assessment specified in section 87458, Medical Assessment and of any special problem or precautions
This requirement was not met as evidency by:
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Administrator will submitt a medical assessment (Physician's Report) for Resident R4 to LPA by 12/26/23.
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Based on LPA's record review at 10:30am, LPA did not observe a medical assessment (Physician's Report) for Resident R4, which poses a potential health or safety risk to residents in care.
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Type B
12/12/2023
Section Cited
CCR
87606(b)(17)(A)
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87506 Resident Records (b)each resident record shall contain at least the following information (17)documents and information required by the following (A) Section 87457, PreAdmission Appraisal.
This requirement was not met as evidence by:
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Administrator will submitt a Pre Admission Appraisal for Resident's R2 and R3 to LPA by 12/26/23.
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Based on LPA's record review at 10:30am, LPA did not observe a Pre Admission Appraisal for residents (R2 and R4), which poses a potential health or safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20231211140253

FACILITY NAME:STERLING SENIOR LIVINGFACILITY NUMBER:
198602239
ADMINISTRATOR:KELLOGG, MICHELLEFACILITY TYPE:
740
ADDRESS:2210 W 234TH STREETTELEPHONE:
(310) 325-2275
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 6DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Ricardo BernalTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility is in disrepair.
Facility staff failed to properly administer resident’s medications.
Facility is not adequately staff
Facility failed to maintain complete and accurate staff records.
INVESTIGATION FINDINGS:
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On 12/12/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit at the facility listed above. LPA met with House Manager, Ricardo “Rickey” Bernal, and explained the purpose of today’s visit.
During today’s visit LPA conducted a facility inspection, interviewed Staff (S1-S2) , interviewed Residents (R1-R6), and received documents pertinent to the investigation. The following documents were received and reviewed. Resident Roster, Centrally Stored Medications, Medication Administration Record (MAR), Admission Agreement, Physicians Report, Resident Appraisal, Needs and Service Plan, Safeguard for Property/Valuables.

The investigation revealed the following:


Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20231211140253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239
VISIT DATE: 12/12/2023
NARRATIVE
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Allegation Facility is in disrepair.

The allegation alleges that the facility is in disrepair.


LPA interviewed S1-S2, two out of two stated the facility is not in disrepair. S1 stated there is a maintenance person who comes in and makes repairs as needed. Dring interviews with Resident’s R1-R6, six out of six stated the facility is not in disrepair and they have no complaints about their accommodations. LPA toured the facility and observed it to be well-maintained. All rooms, bathrooms, and the exterior were checked and found to be compliant with Title 22 regulations. During the course of the investigation, LPA was unable to find any evidence supporting the allegation.
Based on interviews and observations, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Facility failed to maintain complete and accurate staff records.

The allegation alleges that the facility has incomplete staff records.


During the facility file review LPA reviewed and received copies of the required documents to be maintained in the staff files. LPA reviewed four (4) staff files (S1-S4), four out of four files had the required CCL documents including Personnel Record, Fingerprint Clearance, Criminal Record Statement, Health Screening, TB test, Employee Rights, Elder Abuse Index, First Aid/CPR Certificate, Education Verification, Medical Training and Staff Training Logs. During the course of the investigation, LPA was unable to find any evidence supporting the allegation.
Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with Licensee, Albert Pimentel, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 11-AS-20231211140253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239
VISIT DATE: 12/12/2023
NARRATIVE
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Allegation: Facility staff failed to properly administer resident’s medication

The allegation alleges that there have been medication errors.


During record review, LPA reviewed residents Medication Administration Records (MARs) and medications for six residents. Six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records. LPA interviewed Staff (S1 & S1) two out of two staff stated they receive training annually for medication administration. LPA interviewed five Residents (R1-R6), and six (6) out of six (6) residents stated they receive their medications daily and on time. During the course of the investigation, LPA was unable to find any evidence supporting the allegation.
Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Facility is not adequately staffed

The allegation alleges that facility is insufficiently staffed.


During interviews with Resident’s (R1-R6), six (6) out of six (6) stated they receive assistance when needed and have not had to wait to receive assistance. Additionally, six (6) out of six (6) stated the facility has enough staff to provide care to the residents. During interview with Staff (S1-S2) two (2) out of two (2) stated they are able to provide care to residents as needed. Additionally, Staff stated there are two (2) staff on during the day and evening shift, and one on the night. Staff S2 stated additional staff would be useful. S1 stated if they require additional assistance, they can call the administrator and either they would come and help or they send staff from another location to come and assist. During the time of visit, LPA observed all resident cares being met, the residents did not have to wait before they received assistance. LPA reviewed the Staff Roster and observed there are four (4) staff and administrator who work regularly. During the course of the investigation, LPA was unable to find any evidence supporting the allegation.
Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20231211140253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
87458(b)(1)
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87458 Medical Assessment (b)the medical assessment shall include, but not be limited to: (1)A physical examination of the resident indicating the physicians primary diagnosis and secondary diagnosis, if any and results of the examination for communicable
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Administrator will submitt a tuberculosis test for Resident's R2 and R3 to LPA by 12/26/23.
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tuberculosis, other contagious/infectious diseases or other medical conditions wich ould preclude care of the person by the facility.
This requirement was not met as evidence by:
Based on LPA's record review at
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10:30am, LPA did not observe a tuberculosis test for residents (R3 and R4), which poses a potential health or safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7