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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005710
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:06:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231211123948
FACILITY NAME:STERLING SENIOR COMMUNITY IIIFACILITY NUMBER:
306005710
ADMINISTRATOR:NAREZ, ALBERT PIMENTELFACILITY TYPE:
740
ADDRESS:14631 SHINKLE CIRCLETELEPHONE:
(657) 400-9561
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Albert TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
 Facility failed to maintain a complete and accurate staff records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 12/12/23 regarding the above allegations. LPA Ramirez was met by Administrator Albert Narez and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Client Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1-2 interviews (R1 – R2 ), attempted interview of residents# 3-6 (R3-R6), review of six (6) resident records (R1-R6), copies of Resident#1-5 (R1-R5): Medication Administration Record (MAR) for the month of December 2023, review of three (3) personnel records (S1- S3), copies of Staff#3-4 (S3-S4) In-Service Training dated 4/2022-(S4) and 8/2022-(S3) and physical plant tour.

SEE 9099-C for continuation of report.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 313-3425
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231211123948

FACILITY NAME:STERLING SENIOR COMMUNITY IIIFACILITY NUMBER:
306005710
ADMINISTRATOR:NAREZ, ALBERT PIMENTELFACILITY TYPE:
740
ADDRESS:14631 SHINKLE CIRCLETELEPHONE:
(657) 400-9561
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 5DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Albert NarezTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is in disrepair.
Facility staff failed to properly administer resident’s medications.
Facility is not adequately staffed.
Facility failed to maintain a complete and accurate resident’s records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 12/12/23 regarding the above allegations. LPA Ramirez was met by Administrator Albert Narez and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Client Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1-2 interviews (R1 – R2 ), attempted interview of residents# 3-6 (R3-R6), review of six (6) resident records (R1-R6), copies of Resident#1-5 (R1-R5): Medication Administration Record (MAR) for the month of December 2023, review of three (3) personnel records (S1- S3), copies of Staff#3-4 (S3-S4) In-Service Training dated 4/2022-(S4) and 8/2022-(S3) and physical plant tour.

SEE 9099-C for continuation of report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 313-3425
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20231211123948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: STERLING SENIOR COMMUNITY III
FACILITY NUMBER: 306005710
VISIT DATE: 12/12/2023
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Facility is in disrepair- It is alleged the facility is in disrepair. LPA Ramirez conducted both interior and exterior tour of facility plant. LPA Ramirez did not observe facility to be in disrepair during visit. Four (4) out of the four (4) staff interviewed deny this allegation. Two (2) out of the two (2) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility staff failed to properly administer resident’s medications- It is alleged facility staff are not properly administering medications to residents. LPA Ramirez reviewed and compared five (5) out of six (6) residents medications administration records (MAR) for the month of December 2023, to five (5) out of six (6) residents’ prescriptions and Centrally Stored Medications and Destruction Record (LIC 622). Resident#6 (R6) was out of the facility and medications were not available. LPA Ramirez did not find any irregularities during records review. Four (4) out of the four (4) staff interviewed deny this allegation. Two (2) out of the two (2) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility is not adequately staffed- It is alleged the facility is not adequately staffed. LPA Ramirez observed S3 and S4 providing care and supervision to five (5) out of the six (6) residents. Four (4) out of the four (4) staff interviewed deny this allegation. Two (2) out of the two (2) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Facility failed to maintain a complete and accurate resident’s records- It is alleged the facility failed to maintain a complete and accurate resident's records. LPA Ramirez reviewed of six (6) resident records (R1-R6) and did not observe any irregularities or deficiencies to cite. Four (4) out of the four (4) staff interviewed deny this allegation. Two (2) out of the two (2) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of this report and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 313-3425
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20231211123948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: STERLING SENIOR COMMUNITY III
FACILITY NUMBER: 306005710
VISIT DATE: 12/12/2023
NARRATIVE
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2
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Facility failed to maintain a complete and accurate staff records- It is alleged the facility failed to maintain a complete and accurate staff records. LPA Ramirez reviewed three (3) personnel records, out of the four (4) staff present at the facility. During records review, LPA Ramirez discovered two (2) out of the three (3) records reviewed, were missing documented annual training per 1569.625 (b)(2) in their personnel record. Based on review of documents and interviews conducted, the preponderance of evidence standard has been met, therefore the above two allegations are found to be SUBSTANTIATED.

Deficiency is being cited. Exit interview conducted. A copy of this report, 9099-D and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 313-3425
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20231211123948
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: STERLING SENIOR COMMUNITY III
FACILITY NUMBER: 306005710
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2023
Section Cited
CCR
87412(c)
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87412 Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement was not met as evidence by:
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Licensee will document staff training and place in personnel record. Licensee will certify plan to address future staff training and documentation by 12/26/23.
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S3 and S4 did not have documented annually required training per 1569.625 (b)(2) in personnel record.
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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: Tony VasalloTELEPHONE: (323) 313-3425
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5