Community Care Licensing

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024

Document Has Been Signed on 03/12/2024 09:47 AM - It Cannot Be Edited

FACILITY NAME: STERLING COURT	FACILITY NUMBER: 415600223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as there are no health screenings on file for all staff, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2024
	Plan of Correction
1 2 3 4	Health screenings shall be completed for all staff, and proof of corrections to be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024

Document Has Been Signed on 03/12/2024 09:47 AM - It Cannot Be Edited

FACILITY NAME: STERLING COURT	FACILITY NUMBER: 415600223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

Type B

Section Cited

HSC

1569.696(a)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	(1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. . (2) Four hours of training thereafter of in-service training per year on the subject of serving those residents. Based on staff record review, the licensee did not comply with the section cited above, as staff have not received hospice training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2024
	Plan of Correction
1 2 3 4	Plan of correction to be submitted to CCLD by due date.

Section Cited

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

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024

Document Has Been Signed on 03/12/2024 09:47 AM - It Cannot Be Edited

FACILITY NAME: STERLING COURT	FACILITY NUMBER: 415600223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

Type B

Section Cited

CCR

87507(a)(1)

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only. Based on review of clients' records, the licensee did not comply with the section cited above, as admission agreements are printed on both sides of paper for 5 out of 5 resident files reviewed. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2024
	Plan of Correction
1 2 3 4	Admission agreements shall be printed on one side of paper effective immediately. Plan of correction to be submitted to CCLD BY DUE DATE.

Section Cited

	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024