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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005517
Report Date: 03/16/2022
Date Signed: 03/16/2022 03:31:09 PM


Document Has Been Signed on 03/16/2022 03:31 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:STERLING SENIOR LIVING 2FACILITY NUMBER:
306005517
ADMINISTRATOR:KELLOGG, MICHELEFACILITY TYPE:
740
ADDRESS:9608 PUFFIN AVETELEPHONE:
(714) 357-1377
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Michele Kellogg, AdministratorTIME COMPLETED:
03:40 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
Licensing Program Analysts (LPAs) Kathrina Chin and Jessica Cho made an unannounced required annual inspection in this facility. LPAs met with Michele Kellogg, Administrator and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory residents of which one may be bedridden. There are two residents on hospice care.

LPAs were granted entry after completing the COVID-19 screening procedure. For this visit, there are six residents in care and two staff members on the floor. LPAs toured the interior and exterior portions of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 116.8 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. Three fire extinguishers were mounted and charged. For the exterior portion, facility had outdoor furniture and gazebo. The grounds were free of tripping hazards. Side exit door was self-latching and self-closing. LPAs reviewed the COVID-19 mitigation plan of the facility.

An Advisory note (LIC 9105) was also provided.


For this visit, there are no deficiencies cited this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Michele Kellogg, Administrator and copy of this report was left in the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2838
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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 1