306005632-8-30-2024-22-AS-EKIM-D8MUXN-20240830155836

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005632
Report Date: 08/30/2024
Date Signed: 08/30/2024 03:59:18 PM

Document Has Been Signed on 08/30/2024 03:59 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 II		FACILITY NUMBER:	306005632
ADMINISTRATOR:	PASCUAL, KIAN		FACILITY TYPE:	740
ADDRESS:	19112 PAPUA LANE		TELEPHONE:	(714) 357-1377
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	6	CENSUS:	DATE:	08/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Kian Pascual		TIME COMPLETED:	04:05 PM

NARRATIVE

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On August 30, 2024, at 1:05pm, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Administrator (AD) Kian Pascual, and explained the purpose of the visit.

The facility is licensed to operate for six (6) non-ambulatory, of which one (1) can be bedridden and Hospice waiver for 3 residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, one (1) staff bedroom, four (4) bathrooms, living room, family area, dining room, kitchen, attached 2-car garage, and an outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with AD Pascual. There are no obstructions or bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Resident Room 5, Resident Room 6, and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 118.0 degrees F and 119.0 degrees F. A comfortable temperature of 78 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food and emergency water is stored in the garage. The facility has two (2) fire extinguisher that are charged, mounted in the living area and garage, and serviced on April 10, 2024. Smoke/carbon monoxide detectors were operable. The facility conducts Fire/Safety Drill quarterly .

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

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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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 II	FACILITY NUMBER: 306005632
	VISIT DATE: 08/30/2024

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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). A working telephone (714-646-9919) remains available. First Aid Kit contained all the necessary elements.

LPA conducted an audit of resident files (R1-R6), staff files (S1-S4) and medication and medication administration review. LPA Kim conducted 2 staff interviews and 2 resident interviews..

A deficiency was cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6 Chapter 8).

An exit interview was conducted and a copy of this report and the appeal rights were provided to Administrator Kian Pascual.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/30/2024 03:59 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 II	FACILITY NUMBER: 306005632
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed the personnel records for S1, S2, S3, and S4 did not have any training hours for 2024.This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2024
	Plan of Correction
1 2 3 4	Licensee states they will provide the necessary training for S1, S2, S3, and S4, and make sure to keep a current record of completed training. They will send proof of completed training to CCLD via email to edward.kim@dss.ca.gov by POC due date September 13, 2024.

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: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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