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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005630
Report Date: 08/14/2024
Date Signed: 08/14/2024 04:57:38 PM


Document Has Been Signed on 08/14/2024 04:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:STERLING SENIOR COMMUNITY IFACILITY NUMBER:
306005630
ADMINISTRATOR:PASCUAL, KIANFACILITY TYPE:
740
ADDRESS:6081 IVORY CIRCLETELEPHONE:
(714) 357-1377
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Kian PascualTIME COMPLETED:
05:10 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 Analyst (LPA) Jerome Haley conducted an unannounced case management regarding observations made during a complaint visit.

While investigating complaint control number 22-AS-20210723134206, LPA Haley observed an unidentified woman in the facility who refused to identify herself. Once the resident refused to identify herself and provide identification, she was asked to leave the facility.

While touring the facility additional observations were made, LPA Haley observed a pile of debris on the side of the facility including walkers, old blinds, an old wheelchair, and other items. In the kitchen the top right burner on the gas stove would not light, and the dishwasher is not in working condition. Photos were taken of the dishwasher and the pile of debris on the side of the facility.

As a result of today’s case management visit, deficiencies will be cited.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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 2


Document Has Been Signed on 08/14/2024 04:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: STERLING SENIOR COMMUNITY I
FACILITY NUMBER: 306005630

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2024
Section Cited
CCR
87355(d)

1
2
3
4
5
6
7
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agrees to read and review regulation section 87355 Criminal Record Clearance and send a signed statement of acknowledgement and understanding. Administrator Pascual and Licensee Pimenentel agree the unidentified woman is not allowed to come back inside the facility until she is fingerprint cleared and associated to the facility.
8
9
10
11
12
13
14
An unidentified woman was answered the door upon LPA's arrival and refused to provide her name and identification when asked. This poses a health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
08/21/2024
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
Maintenance and Operation (87303)(a)(1):
(a) The facility shall be clean, safe, sanitary and in good repair at all times... for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee Pimenentel and Administrator Pascual agree to have the stove repaired or replaced, the dishwasher will be replaced, and the pile of debris will be removed from the side of the home by the poc due date. Photos of the side of the facility will be emailed by the POC Due date. A receipt was provided for a new dishwasher and a photo will be emailed to LPA once it arrives. A video of the stove lighting unassisted or a receipt will be provided if a new stove is purchased.
8
9
10
11
12
13
14
LPA Haley observed a pile of debris on the side of the facility that needs to be removed. The dishwasher in the kitchen needs to be replaced or repaired and the top left burner on the gas stove needs to be repaired or replaced. Photos were taken of the dishwasher, and the pile of debris on the side of the facility. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2