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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006151
Report Date: 06/28/2022
Date Signed: 06/28/2022 10:18:57 AM


Document Has Been Signed on 06/28/2022 10:18 AM - 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 8FACILITY NUMBER:
306006151
ADMINISTRATOR:PIMENTEL, ALBERTFACILITY TYPE:
740
ADDRESS:15442 COLUMBIA LANETELEPHONE:
(714) 357-1377
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 0DATE:
06/28/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Administrators, Albert Pimentel & Michelle KelloggTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a single story residential home. LPA along with Administrators Albert Pimentel and Michelle Kellogg toured facility at 8:10AM and observed the following:

Fire clearance approval was received on 04/06/22. Structure: Facility is a one story, 6 bedroom and 4 bathroom house with separate garage and gray exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens, towels and hygiene goods such as bath washs and toothpaste Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Facility has 3 extinguishers. Facility has Carbon monoxide detectors in hallway. Facility has audible alarms on all entrance sliding/exit doors. Appliances: Gas Stove, microwave and refrigerator are operational. Toxins: LPA observed toxins secured inside a storage area.. Water Temperature: Tested and recorded between 114.0 to 116.9 degrees F. in facility bathrooms. Reading Material Games, and Equipment:
facility has a physical therapist for exercises, music therapy, coloring books, hand paints and drawing books available Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on one side of facility. LPA observed shaded outdoor seating near front entrance.

Administrator's Certificate observed on wall expiring April 8, 2023



CONTINUED ON 809C.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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 8
FACILITY NUMBER: 306006151
VISIT DATE: 06/28/2022
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Component III Orientation was waived during this pre-licensing visit due to Administrator presently operating other facilities.


Administrator was reminded to obtain larger version of Let Us Know poster in correct size 20 x 26 and to place night-lights. When items are obtained, Administrator to send photos to LPA of updates


No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.


An exit interview was conducted with Administrator Albert Pimentel 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: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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