366413246-11-15-2024-56-AS-MECA-DB2U35-20241115141300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366413246
Report Date: 11/15/2024
Date Signed: 11/15/2024 02:13:05 PM

Document Has Been Signed on 11/15/2024 02:13 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	STERLING INN		FACILITY NUMBER:	366413246
ADMINISTRATOR/ DIRECTOR:	BARBER, DONALD		FACILITY TYPE:	740
ADDRESS:	17738 FRANCESCA ROAD		TELEPHONE:	(760) 245-2999
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92392
CAPACITY: 185	TOTAL ENROLLED CHILDREN: 0	CENSUS: 131	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:25 AM
MET WITH:	Donald Barber-Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:28 PM

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Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator, Donald Barber and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) licensed capacity for (185) current census (131). The facility has (166) apartment bedrooms with bathrooms included, reception area, library room, beauty/barber room, billiard room, (4) laundry rooms, offices, card room, media room, regency room, craft room, bistro room, lounge, exercise room, club room, garden room and a handicap bathroom. LPA was accompanied by the Administrator to conduct a general overall inspection, which included, but was not limited to the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 73, 74 and 73 degrees fahrenheit. Water temperature measured at 118, 112.8, 120, 116.1 and 115.7 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating fire extinguishers, smoke detectors, signal alarms and carbon monoxide alarms. Posters such as personal rights, CCL complaint poster, CCL license, ombudsman, and facility sketch were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for residents/staff files. Medications were kept in Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Facility has a variety of food available. Dishes, cups, and utensils were stored properly.

Nedra Brown	TELEPHONE: (951) 202-5776
Michelle Echeverria	TELEPHONE: 951-248-0345
	DATE: 11/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: STERLING INN	FACILITY NUMBER: 366413246
	VISIT DATE: 11/15/2024

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Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed resident files for admission agreements, physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA audited medication and observed that medication did not match medication records. LPA observed that the facility did not have the physical supply of PRN according to the resident's medical record. Deficiency issued. LPA reviewed the infection control plan, liability insurance, disaster drills and emergency disaster plan.

One deficiency was cited during this visit. An exit interview was conducted, and this report LIC809, LIC809C, LIC809D and appeal rights were discussed and provided to Administrator, Donald Barber.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle Echeverria	TELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 02:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: STERLING INN	FACILITY NUMBER: 366413246
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the administrator did not comply with the section cited above by not having the PRN medication according to the resident's medication record which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Administrator stated that medication will be audited to match with records and a refresh training will be conducted with staff on the regulation cited. Administrator will send a copy of the attendance sheet with staff's signature to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

Nedra Brown	TELEPHONE: (951) 202-5776
Michelle Echeverria	TELEPHONE: 951-248-0345
	DATE: 11/15/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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