<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602239
Report Date: 06/21/2024
Date Signed: 06/21/2024 03:00:56 PM

Document Has Been Signed on 06/21/2024 03:00 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:STERLING SENIOR LIVINGFACILITY NUMBER:
198602239
ADMINISTRATOR/
DIRECTOR:		KELLOGG, MICHELLEFACILITY TYPE:
740
ADDRESS:2210 W 234TH STREETTELEPHONE:
(310) 325-2275
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 6DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:23 AM
MET WITH:Ricardo Bernal TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/21/24 at 8:23 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with House Manager Ricardo Bernal.

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. Annual fees are current.



This facility consists of an office area, foyer, kitchen, living room, dining area, a wheelchair ramp (located on the right side of the house), five (5) resident bedrooms, one staff bedroom, two (2) bathrooms, backyard patio, and a garage (washer/dryer). The facility is clean, sanitary, and in good repair.

The House Manager accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 111 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
Document Has Been Signed on 06/21/2024 03:00 PM - It Cannot Be Edited


Created By: Regina Cloyd On 06/21/2024 at 02:23 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: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
A plan for incidental medical … and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above for resident #1 (R1) which posed a potential health risk to person in care. During medication review, LPA Cloyd did not observe Eliquis, listed on June 2024 MAR, being given to R1 from June 1 - June 20, 2024.
POC Due Date: 07/08/2024
Plan of Correction
1
2
3
4
Staff resolved the issue by contacting the Hospice agency. Hospice sent an updated medication list discontinuing Eliquis as of 06/21/24. The Administrator will train staff on completing a monthly medication review and send evidence to regina.cloyd@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. The facility has a total of three fire extinguishers, last serviced March 20, 2024. House Manager tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

5 staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions.

6 resident records were reviewed and, 6 out of 6 resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed.

Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. LPA did not observe one medication being given to Resident #1 from June 1 – June 20, 2024 which poses a potential health risk to client in care.

An exit interview was conducted, technical assistance provided, plan of correction developed, and a copy of this report and appeals was discussed and left with House Manager Ricardo Bernal.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7