306006007-7-14-2022-22-AS-CDPO-CGBV92-20220714161337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006007
Report Date: 07/14/2022
Date Signed: 07/14/2022 04:13:42 PM

Document Has Been Signed on 07/14/2022 04:13 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 VI		FACILITY NUMBER:	306006007
ADMINISTRATOR:	KELLOGG, MICHELLE		FACILITY TYPE:	740
ADDRESS:	140 N WHEELER ST		TELEPHONE:	(714) 538-9615
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 4	DATE:	07/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Administrator - Kian Pascual		TIME COMPLETED:	04:35 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) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Kian Pascual about visit. AD Pascual provided consent for staff on duty (S1) (Mardie Rodriguez) to give LPA De Perio a tour. As of 7/14/22, there are no active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the main entrance door. The PUB475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA observed the Administrator Certificates for Kian Pascual which expires on 5/25/24, Alberto Narez which expires on 4/8/23, and Michelle Kellogg’s certificate which stated that it expired on 10/8/21. LPA De Perio had S1 contact AD Kellogg for LPA De Perio to inquire about new certificate needing to be posted and was informed that she has not yet received the renewed AD certificate. AD Kellogg provided proof that her certificate is active and expires on 10/8/23. LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for six residents, of which 1 may be bedridden and 4 may be on hospice. Currently, there are a total of 4 residents in care, of which 1 is on hospice. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilet was operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 105.1 degrees Fahrenheit. LPA De Perio observed hand washing signs posted in each bathroom and in the kitchen.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 VI	FACILITY NUMBER: 306006007
	VISIT DATE: 07/14/2022

NARRATIVE

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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to the residents in care. Fire extinguishers were charged, mounted and located in multiple areas of the facility (front entrance, kitchen, garage, and living room).

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There is one exit gate in the backyard, which was self-closing and self-latching. Facility had back-up emergency food and water supply, located in the kitchen and garage.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage and hallway cabinets. Medications were locked in a cabinet located next to the staff room. Toxins were also observed to be locked and inaccessible to residents.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with S1. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD Pascual to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Pascual and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC809 (FAS) - (06/04)

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