<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006151
Report Date: 12/12/2023
Date Signed: 12/12/2023 06:21:12 PM

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: 5DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Michelle Kellogg TIME COMPLETED:
05:59 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.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/12/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial complaint visit at this facility. LPA was greeted by caregiver Erly Wilson. Wilson contacted licensee Michelle Kellogg who later arrived at the facility. LPA explained the purpose of the visit is to investigate the allegations mentioned.

The investigation consisted of the following: Interviews with staff #1-#2 and licensee, witnesses #1, and resident #4. A review of resident #1-#5 (R1-R5) service records and other pertinent documents associated with this complaint. A physical tour of the facility was conducted.

(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: 12/12/2023
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
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: 12/12/2023
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
26
27
28
29
30
31
32
INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Facility is in disrepair.
It is alleged the facility is in disrepair. The complainant reported the physical plant is not maintained in good condition.

On 12/12/23 between 2:01 pm - 2:47 pm an inspection the entire facility. The inspection revealed that the central stove burner was not operable at 2:01 pm. The bathroom in resident's room #6 is missing a window covering for privacy. At 2:21 pm resident #4 (R4) who occupies room #6 was interviewed and who stated preferred having a window covering for privacy in the private bathroom. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Allegation #2: Facility staff failed to properly administer the resident’s medications.
The details of the complaint alleged the facility is not properly administering resident's medications. The complainant reported the facility is not administering and storing medications properly.

On 12/12/23 between 2:01 pm - 2:47 pm inspection the entire facility. At 2:05 pm the Department identified refrigerated prescription medications were not stored properly for residents #2 and #5 (R2 and R5). (R2's) was in a locked box with a key attached and key not stored away from box. (R5's) medications were stored in a snap box plastic container with no lock. Both (R2 and R5) medications were accessible to other residents diagnosed with dementia. Based on the information gathered, there is sufficient evidence to support 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 being cited on the attached LIC 9099-D.

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

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 395-3554
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
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: 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2024
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will ensure the facility is maintained in good repair at all times. Licensee will repair central stove burner and have a window covering for room #6 bathroom. Proof of correction must be sent to LPA by due date: 01/12/24 via email.ernand.dabuet@dss.ca.gov
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above. LPA identified window covering missing for room #6 and central stove burner not in working condition. The violaiton which poses/posed a potential health, safety or personal rights risk to persons in care
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 12/12/2023
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: 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: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2023
Section Cited
CCR
87465(2)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

1
2
3
4
5
6
7
Licensee will ensure the facility is to store all medications for residents in locked storage not accessible to other residents. Proof of correction must be sent to LPA by due date: 12/13/23 via email.ernand.dabuet@dss.ca.gov
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above. LPA identified refrigerated medications for resident (R2&R5) not locked up storage accessible to other residents. The violaiton which poses/posed an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 12/12/2023
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