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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006358
Report Date: 02/16/2024
Date Signed: 02/16/2024 02:19:38 PM


Document Has Been Signed on 02/16/2024 02:19 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:STERLING SENIOR COMMUNITY 12FACILITY NUMBER:
306006358
ADMINISTRATOR:FILIO, JEREMIASFACILITY TYPE:
740
ADDRESS:10111 KAMUELA DRIVETELEPHONE:
(714) 357-1377
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: DATE:
02/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Michelle Kellogg - LicenseeTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility and was greeted and granted entry by Michelle Kellogg, Licensee. LPA also met Albert Pimentel, Licensee and Kian Pascual, Employee. An application to operate a Residential Care Facility for the Elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on 5/10/2023.

Structure - The facility is a one-story home with six resident bedrooms, four bathrooms, one staff room, kitchen, dining area, living room, attached two-car garage and backyard. LPA observed facility to be clean, sanitary and safe.

Resident Bedrooms/Bathrooms - All resident bedrooms are private with all the necessary furnishings, ample lighting and screened windows. Bedrooms with sliding doors are equipped with alarms. Bedroom 2 has been approved to house the bedridden resident. Hot water initially measured over 120 degrees Fahrenheit. Licensee adjusted the hot water heater. After approximately thirty minutes, LPA measured hot water in resident bathrooms. Hot water measured at 120 degrees Fahrenheit in the bathrooms that share a hallway with the staff room and medication cabinet. Hot water in bathroom nearest to the living room measured at 116.3 degrees Fahrenheit. Hot water in the remaining bathroom measured at 111.2 degrees Fahrenheit. LPA advised facility to maintain a water log since they had to adjust the water during the inspection.

Medications, Files, First-Aid Kit will all be stored in cabinets in the hallway. First aid kit has the necessary components.

Activities - The facility has a calendar of activities including but not limited to: board games, cooking classes, exercise, arts and crafts, movie nights and more..
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STERLING SENIOR COMMUNITY 12
FACILITY NUMBER: 306006358
VISIT DATE: 02/16/2024
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Kitchen/Food Service/Emergency Food & Water/Toxins - There is a 7-day supply of non-perishable food on hand. Emergency food supply is located in the garage. Facility ordered 8 gallons water for emergency use. LPA verified the water is scheduled to arrive at the facility on 2/17/2024. LPA observed knives and sharp objects to be locked in a drawer in the kitchen. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in the garage and under the kitchen sink. LPA noted the toxins stored in the kitchen are stored separate from food and food-handling items.

The Fire Clearance, was approved by a fire inspector of Huntington Beach Fire Department on 10/25/2023. All fire extinguishers are fully charged. The service tags indicate they were last serviced on 1/16/2024. LPA observed the smoke/carbon monoxide detectors to be dual detectors. Detectors were tested and observed to be operational.

Emergency Phone Numbers, Exit Plan, Activity Calendar & Menu are all posted and available for review.

Component III was reviewed and provided via PDF. Comp III provides a general overview of how to maintain compliance in accordance with regulations.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report and Component III presentation were provided to facility
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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