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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602239
Report Date: 11/09/2022
Date Signed: 11/10/2022 08:20:31 AM

Document Has Been Signed on 11/10/2022 08:20 AM - 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 LIVINGFACILITY NUMBER:
198602239
ADMINISTRATOR:KELLOGG, MICHELLEFACILITY TYPE:
740
ADDRESS:2210 W 234TH STREETTELEPHONE:
(310) 325-2275
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 6DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:RICARDO BERNAL/KIAN PASCUALTIME COMPLETED:
02:00 PM
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On 11/9/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called Administrator Michelle Kellogg and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with House Manager Ricardo Bernal and explained the purpose of today's visit.

The facility is licensed for two (2) ambulatory and four (4) non-ambulatory, of which two (2) may be bedridden. Facility has two approved hospice waivers. LPA observed six (6) residents and two (2) direct staff present during today's visit. Staff Kian Pascual arrived later and joined the visit. The facility has an approved mitigation plan.

LPA Montoya toured the inside and outside grounds of the facility with House Manager Ricardo Bernal. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance and a visitors log. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in a cabinet in the hallway; sufficient paper, cleaning, and disinfecting supplies were observed.

All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place.

REPORT CONTINUED IN LIC 809C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
FACILITY NUMBER: 198602239
VISIT DATE: 11/09/2022
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 The water temperature measured at 107.0 degrees Fahrenheit in the common bathroom and 106.0 degrees Fahrenheit in the shared bedroom. A comfortable temperature was maintained in the facility. All bedrooms and living room have smoke detectors and they are all interconnected and operational. Carbon monoxide detector located and mounted in the hallway is operational.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives were kept in a locked storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. Two fire extinguishers last serviced 2/10/2022 are fully charged. Outside grounds were toured, and no bodies of water were observed.

Advisory Notes were issued, and Technical Assistance was provided.

LPA observed the following deficiencies:

· Dishwasher is not operable.

· Black side gate is rusted and broken.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Staff Kian Pascual.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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Document Has Been Signed on 11/10/2022 08:20 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 11/09/2022 at 01:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022

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 and interview, the licensee did not comply with the section cited above .LPA Montoya observed the black side gate is rusted and broken and the dishwasher is not operable. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Administrator shall fix or replace the side gate and the dishwasher. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 11/28/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022


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