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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800235
Report Date: 07/27/2022
Date Signed: 07/27/2022 12:22:37 PM

Document Has Been Signed on 07/27/2022 12:22 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:STERLING HOME, THEFACILITY NUMBER:
361800235
ADMINISTRATOR:HOWARD, DANIELLEFACILITY TYPE:
735
ADDRESS:2431 S SEAGULL AVETELEPHONE:
(909) 443-7054
CITY:ONTARIOSTATE: CAZIP CODE:
91761
CAPACITY: 5CENSUS: 4DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Danielle HowardTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 07/27/2022 at 09:30 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Staff Tony Jones and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Staff Jones reported that they have four (4) clients at the facility. Administrator Danielle Howard was contacted and arrived during the visit. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Howard. Per documents review, Mitigation Plan was submitted 01/21/2021. Also, Administrator Howard reported that the facility’s Infection Control Plan was submitted 06/30/2022.

LPA Brown observed the facility with Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. Signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect clients from infection during pandemic. LPA Brown toured the facility, and all rooms and bathrooms have hand soap and paper towels. However, LPA Brown observed common towel in the clients’ bathroom. LPA Brown will be issuing Technical Advisory Note for this issue. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of surgical masks, gloves, isolation gown, hand sanitizers, wipes and N95 respirator masks available at the facility. LPA Brown went over the various recommended training for facility staff with Administrator Howard in relation to COVID-19 and Administrator Howard reported to LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

**** Continuation in LIC809C ****
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: STERLING HOME, THE
FACILITY NUMBER: 361800235
VISIT DATE: 07/27/2022
NARRATIVE
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LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Howard informed LPA Brown that staff have not been fit tested for N95 masks at this time. LPA Brown will be issuing a Technical Advisory Note during today's inspection for staff not being fit tested for N95 masks due to the facility not having Covid-19 positive clients and staff, and N95 masks needs to be worn when a client is COVID-19 positive or under observation while awaiting test results.


Additionally, Administrator Howard reported that all four (4) clients are not vaccinated and boosted and only Staff 11 (S11) had dose 1 and dose 2 but no booster and no exemption record at the facility. Administrator Howard also added that no exemption letter was submitted for all the staff that are not vaccinated and boosted. In addition, Administrator Howard indicated all staff that are not vaccinated are testing every week for covid-19 infection. LPA Brown will be issuing a deficiency on this issue as this pose potential risks to clients in care.

Moreover, LPA Brown observed all staff and clients are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any event of any COVID-19 related and/or suspected illnesses.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: STERLING HOME, THE
FACILITY NUMBER: 361800235
VISIT DATE: 07/27/2022
NARRATIVE
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During the tour of the facility at around 10:15 AM, LPA Brown observed one (1) gallon of bleach, two (2) gallons of laundry detergent in the garage not locked and accessible to clients. Staff 2 reported to LPA Brown that their clients can access their garage. Also, LPA Brown found one (1) screw driver in the kitchen drawer, not locked and accessible to clients in care. LPA Brown will be issuing a deficiency for this issue as this pose immediate safety risks to clients in care. During the visit, Staff 2 immediately locked the gallon of bleach and two (2) gallons of laundry detergents and a gallon of deck brightener.

Also, LPA Brown observed the hot tub cover in disrepair, without secured lock in the backyard at around 10:30 AM, and LPA Brown observed one (1) gallon of deck brightener inside the hot tub, not locked and accessible to clients in care. LPA Brown will be issuing a deficiency for this issue as this pose immediate health and safety risk to clients in care.

An exit interview was conducted with Administrator Danielle Howard and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Note and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/27/2022 12:22 PM - It Cannot Be Edited


Created By: Melody Brown On 07/27/2022 at 11:34 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: STERLING HOME, THE
FACILITY NUMBER: 361800235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(e)
Building and Grounds
(e) All licensees serving children or serving clients who have physical handicaps, mental disorders, or developmental disabilities shall ensure the inaccessibility of pools, including swimming pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds or similar bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above by having the hot tub cover in disrepair and not lock which pose an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2022
Plan of Correction
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2
3
4
Licensee stated to repair/replace the hot tub cover and make sure that it will be locked and inaccessible to clients in care and submit proof to LPA Brown by POC due date.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not locking the one (1) gallon of bleach, two (2) gallons of laundry soap, one (1) screwdriver, one (1) gallon of deck brightener which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2022
Plan of Correction
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Licensee stated to train all staff on CCR 80087(g) and submit proof to LPA Brown by POC due date. Also, Licensee stated to submit Statement of Understanding on CCR 80087(g) to LPA Brown by POC due date.
Gallon of bleach, two (2) gallons of laundry detergent and a gallon of deck brightener were immediately locked away during the visit.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 07/27/2022 12:22 PM - It Cannot Be Edited


Created By: Melody Brown On 07/27/2022 at 11:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: STERLING HOME, THE
FACILITY NUMBER: 361800235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
121125,120140,120275


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring the personal rights of person in care to live in a safe, healthy, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that the Licensee did not verify workers vaccination, booster or exemption status or unvaccinated worker's test results as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021 which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee stated to submit proof of vaccination/booster/exemption of all staff - Staff 1, Staff 2, Staff 3, Staff 4, Staff 5, Staff 6, Staff 7, Staff 8, Staff 9, Staff 10, Staff 11, Staff 12, Staff 13, and Staff 14 to LPA Brown by POC due date. Also, Licensee stated to update all staff vaccination record at the facility by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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