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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602239
Report Date: 06/15/2021
Date Signed: 06/17/2021 11:35:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:STERLING SENIOR LIVINGFACILITY NUMBER:
198602239
ADMINISTRATOR:KELLOGG, MICHELLEFACILITY TYPE:
740
ADDRESS:2210 W 234TH STREETTELEPHONE:
(310) 325-2275
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 6DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Michelle Kellogg/Alberto Pimentel/Kian PascualTIME COMPLETED:
03:45 PM
NARRATIVE
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On 6/15/2021 at 12:50 pm, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Montoya called the facility, spoke with House Manager Ricardo Bernal and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. Licensee has timely submitted a mitigation plan report pending CCLD’s review and approval.

The facility is licensed for two (2) ambulatory and four (4) non-ambulatory, of which two (2) may be bedridden. Facility has two approved hospice waivers. LPA observed six (6) residents of which two (2) are on hospice care. LPA observed two staff on duty during the visit.

At around 1:00 pm, LPA met with the House Manager and they both toured the inside and outside grounds of the facility. Administrator Alberto Pimentel, Licensee Michelle Kellogg and Assistant Administrator Kian Pascual arrived later and joined the visit.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance and a visitors log. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the back patio in addition to the resident’s bedroom. LPA observed staff and residents maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility. LPA reviewed the facility’s surveillance testing records, one out of four staff tested with Covid-19 every seven days.

All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

REPORT CONTINUED IN LIC 809C

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 LPA's observation and interview, the licensee did not comply with the section cited above. LPA observed toxins such as ajax powder, awesome all purpose cleaner, oven grill spray inside an unlocked cabinet underneath the kitchen sink accessible to residents. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2021
Plan of Correction
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Licensee shall keep all toxins inaccessible to residents by the POC 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.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2021
LIC809 (FAS) - (06/04)
Page: 2 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview, the licensee did not comply with the section cited above. LPA observed a ladder, empty boxes, a wheelchair and other miscellaneous items in outdoor passageway to the right side gate. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2021
Plan of Correction
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Licensee agreed to remove all obstructions in outdoor passageways by the POC 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.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2021
LIC809 (FAS) - (06/04)
Page: 3 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239
VISIT DATE: 06/15/2021
NARRATIVE
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Furniture in the living room are marked or separated, and 6 feet apart from each other. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 114.0 degrees F. in the common bathroom and 114.1 degrees Fahrenheit in the shared bedroom. A comfortable temperature was maintained in the facility. All bedrooms and living room have smoke detectors and they are all interconnected and operational. Carbon monoxide detector located and mounted in the hallway is operational.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives were kept in a locked storage cabinet. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. Two fire extinguishers last serviced 2/10/2021 are fully charged.

Outside grounds were toured, and no bodies of water were observed.

LPA observed the following deficiencies:

· Obstructions in outdoor walkways

· Toxins accessible to residents

· Left side gate is locked with a padlock.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Assistant Administrator Kian Pascual.

Advisory Notes were issued, and Technical Assistance was provided.

An exit interview was conducted, and a copy of this report was provided to Assistant Administrator Kian Pascual.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
LIC809 (FAS) - (06/04)
Page: 6 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: STERLING SENIOR LIVING
FACILITY NUMBER: 198602239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(6)
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, buidling or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring window against intruders, with permission from the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview, the licensee did not comply with the section cited above. LPA observed and took photos of the left side gate locked with a padlock. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2021
Plan of Correction
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Licensee removed the padlock and kept the left side gate unlocked during the visit.
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.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2021
LIC809 (FAS) - (06/04)
Page: 7 of 7