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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005632
Report Date: 08/09/2022
Date Signed: 08/09/2022 03:13:43 PM


Document Has Been Signed on 08/09/2022 03:13 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 COMMUNITY IIFACILITY NUMBER:
306005632
ADMINISTRATOR:PASCUAL, KIANFACILITY TYPE:
740
ADDRESS:19112 PAPUA LANETELEPHONE:
(714) 357-1377
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrators Michelle Kellogg and Kian PascualTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit.

During the visit LPA toured the facility with caregiver Ervin Ortiz. During inspection Administrators Michelle Kellogg and Kian Pascual arrived during visit. Facility is a 7 bedroom,( 6 resident bedrooms 1 staff bedroom) and 4 bathrooms single story home. There are 6 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring 5/25/24. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed had working wash basin, contained soap, toilet paper and paper towels. Residents were observed relaxing in the Living room watching TV. Facility has operating smoke detectors, carbon monoxide detectors and audible alarms for each sliding door entrance/exit. Facility has 3 fire extinguishers which are fully charged. Facility has ample supply of PPE. Facility has 3 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. Facility has Infection Control Plan. Facility has a secure location for Toxins. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. LPA reviewed Residents files during visit. LPA observed 6 out of 6 resident files. Residents emergency contact information and Physicians reports are current. Facility has several designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator and a copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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