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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600223
Report Date: 02/20/2025
Date Signed: 02/20/2025 05:33:30 PM

Document Has Been Signed on 02/20/2025 05:33 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:STERLING COURTFACILITY NUMBER:
415600223
ADMINISTRATOR/
DIRECTOR:		CHARLES, SARAH ST.FACILITY TYPE:
740
ADDRESS:850 NO. EL CAMINO REALTELEPHONE:
(650) 344-8200
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 24TOTAL ENROLLED CHILDREN: 0CENSUS: 21DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Sarah St.Charles & Novie VillafuerteTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility, which consists of 21 assisted living apartments on the ground floor of this four story community, including a designated dining room. All units have private patios and small kitchens with refrigerators and microwaves. Emergency signal system is tested and consists of pull cords in bathrooms, living rooms and bedrooms, which sends audible alert to staff. Operable carbon monoxide detectors are installed in all apartments and tested. There are no accessible bodies of water or fire safety hazards observed. Medications and sharps are stored in locked medication room--inaccessible to clients--a comfortable temperature is maintained, passageways are clear, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material and hygiene supplies are maintained. Hot water temperature tested at 108 degrees in room 109. Food supply and first-aid kit are inspected. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records, including training. Client files and medications records are reviewed.
Novie Villafuerte is a certified RCFE administrator (x1/26) that oversees facility operations. Executive director Sarah St. Charles oversees the entire building, which includes the independent units not subject to licensing authority.

The following information is requested to be submitted to CCL by 3/6/25:

• LIC 500 Personnel REport



Deficiencies of the California Code of Regulations, Title 22 are cited on following pages. See also Technical Advisory Notes--2 pages.
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891
DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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Document Has Been Signed on 02/20/2025 05:33 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: STERLING COURT
FACILITY NUMBER: 415600223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as cleaning liquid Resolve is stored in room 114, occupied by client #2. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Resolve was removed from room 114 in LPA's presence.
Deficiency corrected and cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025

LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 02/20/2025 05:33 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: STERLING COURT
FACILITY NUMBER: 415600223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
HSC
1569.17(b)(1)(C)
Licensing
(C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene. Any nurse assistant or home health aide meeting the requirements of Section 1338.5 or 1736.6, respectively, who is not employed, retained, or contracted by the licensee, and who has been certified or recertified on or after July 1, 1998, shall be deemed to meet the criminal record clearance requirements of this section. A certified nurse assistant and certified home health aide who will be providing client assistance and who falls under this exemption shall provide one copy of their current certification, prior to providing care, to the residential care facility for the elderly. The facility shall maintain the copy of the certification on file as long as the care is being provided by the certified nurse assistant or certified home health aide at the facility. Nothing in this paragraph restricts the right of the department to exclude a certified nurse assistant or certified home health aide from a licensed residential care facility for the elderly pursuant to Section 1569.58.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above in 1 out of 2 staff records reviewed, which poses an immediate health, safety or personal rights risk to persons in care.
- Staff #2 has worked at facility since 8/2024 as a caregiver, but does not have criminal record clearance nor association with facility. Civil penalty of $500 is assessed for maximum of 5 days for initial violation.
POC Due Date: 02/21/2025
Plan of Correction
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Staff #2 cannot work or be present with clients until criminal record cleared and associated with facility.
Plan/proof of correction to be sent to CCLD BY DUE DATE
Section Cited

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2025 05:33 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 BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: STERLING COURT
FACILITY NUMBER: 415600223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of facility records, the licensee did not comply with the section cited above, as emergency disaster drills are not conducted quarterly. Instead, staff received training on disaster response in May, August and November 2024. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Plan/proof of correction will be submitted to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025

LIC809 (FAS) - (06/04)
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