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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006151
Report Date: 12/22/2023
Date Signed: 12/22/2023 11:06:24 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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 Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231211124236
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: 6DATE:
12/22/2023
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Albert Narez TIME COMPLETED:
11:17 AM
ALLEGATION(S):
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Facility is not adequately staffed.
Facility failed to maintain complete accurate resident records.
Facility failed to maintain complete and accurate staff records.
INVESTIGATION FINDINGS:
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On 12/22/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsquent unannounced complaint visit to this facility. Upon arrival at the facility, LPA Dabuet was greeted by house manager Erly Wilson who contacted the administrator Albert Narez who later join for the visit. The purpose of the visit was provided to Narez is to investigate the allegations mentioned above.

The investigation consisted of the following: Interviews conducted with staff 1- 2 (S1-S2) and interview with resident #3 and #4 (R3-R4), witness #1(W1). Inquiry questions were relevant to the nature of the complaint. A review of service records for resident #1- #6 (R1-R6) and staff #1- #5 (S1-S5). A tour of the facilty on 12/12/23 and 12/22/23.

(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 395-3554
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
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
Control Number 22-AS-20231211124236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 8
FACILITY NUMBER: 306006151
VISIT DATE: 12/22/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #3: Facility is not adequately staffed.

It is alleged the facility is operating with inadequate As a result of the complaint, the complainant was concerned that the facility operates with a minimum number of staff.



On 12/12/23 between 3:03 pm – 5:59 pm, the Department interviewed (2) out of (2) staff #1-#2 (S1-S2) revealing there are two caregivers for supervision to five residents during shift 7:00 am through 7:00 pm. (S1-S2) stated an “awake” staff in place to work overtime when any residents post restlessness behavior or incontinent assistance. Service records revealed residents #1 and #2 (R1-R2) are diagnosed with dementia.
On 12/22/23 between 8:30 am - 9:24 am the Department reviewed resident #6 (R6) who was admitted on 12/16/23 and requires continuous bed care, bowel & bladder Impairment, and unable to evacuate according to (R6's) Physician's Report (date 12/14/23). (R1) diagnosed with dementia requires observation/night supervision and is not able to self-evacuate, needs assistance with toileting, and a fall risk according to (R1's) Pre-placement Appraisal Information LIC 603 (date: 07/20/23) Appraisal/Needs Services Plan (date: 07/28/23), and Physician's Report LIC 602 (date: 07/13/23). (R3 and R5) both are hospice residents. (R3) is bowel & bladder Impairment, who cannot self-evacuate, and requires observation/night supervision according to (R3's) Physician's Report (date: 07/30/23) and Resident Appraisal LIC 603 A (date: 07/30/23). (R5) is bed bound, has seizures, a falls risk, requires maximum (ADL) assistance, and is unable to self reposition according to (R5’s) Physician’s Report (date: 01/19/22). Based on the gathered information, there is sufficient evidence to support the allegation mentioned above. The facility requires a permanent night staff for care and supervision for (4) out of (6) residents.

Allegation #4: and Facility failed to maintain complete accurate resident records.

The details of the complaint alleged that the facility failed to maintain complete and accurate resident records. The complainant was concerned the facility was not operating within Title 22 requirements.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 395-3554
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20231211124236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 8
FACILITY NUMBER: 306006151
VISIT DATE: 12/22/2023
NARRATIVE
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On 12/12/23 between 1:52 pm - 2:46 pm, the Department conducted a review of resident #1-#5 (R1-R5) service files. The review of resident #1 (R1) records revealed to be complete. (R2), (R3), and (R4) did not include a Safeguard for Property Valuables (LIC 621) on file. (R4) was admitted on 11/20/23 and did not include an Appraisal/Needs and Services Plan (LIC 625) and (R5) LIC 625 is incomplete missing page 3 and 4. (R6) admitted on 12/16/23 did not have Identification and Emergency Information (LIC 601). Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Allegation #5: Facility failed to maintain complete and accurate staff records.

The details of the complaint alleged that the facility failed to maintain complete and accurate staff records. The complainant was concerned because the facility was not operating within Title 22 requirements.

On 12/12/23 between 3:05 pm - 4:30 pm, the Department conducted a review of staff #1-#5 (R1-R5) personnel files. Upon examination of staff #2 (S2) hired on 07/07/22, file was found incomplete. (S2), did not have Health Screening LIC 503, Employee Rights LIC 9052, Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders SOC 341 and TB Test. (S1), (S3), (S4) and (S5) personnel files were found to be within Title 22 regulations and accurate and complete. Based on the information gathered, there is sufficient evidence to corroborate the allegation mentioned above.

Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099-D.

An exit interview was conducted with Albert Narez, and a hard copy of the report along with appeal rights.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 395-3554
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20231211124236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 8
FACILITY NUMBER: 306006151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87705(c)(4)(A)
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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.
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Licensee shall ensure there's always one aware staff during night shift to provide care and supervision to residents with dementia and hospice. Licensee shall self-certify understanding of the section cited herein and shall comply. POC shall be submitted to CCLD via email to ernand.dabuet@dss.ca.gov by the POC due date, 01/05/23.
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This requirement was not met as evidenced by:
On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed there are two caregivers providing care and supervision to five residents during day shift from 7:00 AM through 7:00 PM. S1 and S2 stated an awake staff is placed to work overtime at night from 7:00 PM - 7:00 AM when any residents pose a restless behavior. Based on interview with S1 and S2 and LPA's records review, it was revealed that four residents (R1, R3, R5 &R6) need close supervision due to their medical conditions, however S1 and S2 stated there are no on-duty staff during night shift unless needed. This poses a potential health, safety, and/or personal rights risk to persons in care.
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Type B
01/05/2024
Section Cited
CCR
87506(a)
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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Licensee shall ensure all resident records are complete and accurate. Administrator agreed to obtain all missing resident records and shall submit copies to CCLD via email to ernand.dabuet@dss.ca.gov by the POC due date, 01/05/24.
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This requirement was not met as evidenced by:
Based on record review. LPA reviewed records of 4 out of 6 residents (R1-R6). Service records were incomplete (see LIC 9099-C). This poses a potential health, safety, and/or personal rights risk to persons in care.
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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: Janae HammondTELEPHONE: (323) 395-3554
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20231211124236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 8
FACILITY NUMBER: 306006151
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87412(a)(11-12)
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87412 Personnel Records
a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:....
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Licensee shall ensure all staff records are complete and accurate. House Manager agreed to obtain all missing staff records and shall submit copies to CCLD via email to ernand.dabuet@dss.ca.gov by the POC due date, 01/05/24.
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This requirement was not met as evidenced by: Based on record review, staff #3 had an incomplete personnel file and missing required licensing forms. (See LIC 9099-C) This violation poses a potential health and safety to residents in care.
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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: Janae HammondTELEPHONE: (323) 395-3554
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5