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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320076
Report Date: 04/19/2022
Date Signed: 04/19/2022 03:54:10 PM

Document Has Been Signed on 04/19/2022 03:54 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:STERLING SENIOR COMMUNITY VFACILITY NUMBER:
198320076
ADMINISTRATOR:NAREZ, ALBERTO PIMENTELFACILITY TYPE:
740
ADDRESS:1200 W 226THTELEPHONE:
(714) 891-0088
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 6CENSUS: 6DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Alberto Pimentel NArezTIME COMPLETED:
04:00 PM
NARRATIVE
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On 4/19/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with House Manager Arnold Mendoza and explained the purpose of today’s visit. The facility is an RCFE licensed for (1) ambulatory and (5) non- ambulatory residents. Facility has a hospice waiver for 2. LPA and staff were later joined by administrator Alberto Pimental Narez.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: (6) six client bedrooms, 2 client bathrooms, 1 staff room, a guest/staff bathroom, living room, dining area, kitchen and detached garage. Backyard had a covered seating area with dining table and six chairs. Kitchen was inspected and observed to be clean and operational.

LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. Two fully charged fire extinguishers were found near dining room and living room.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, a 30-day supply of Personal Protective Equipment (PPE) is available and sign in and out logs for visitors and staff are present in the facility.

Deficiencies cited on attached 809-D.

Advisories are on attached 9102-AN

An exit interview was conducted, and a copy of this report was provided to Alberto Pimental Narez, Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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 04/19/2022 03:54 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 04/19/2022 at 03:03 PM
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
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: STERLING SENIOR COMMUNITY V
FACILITY NUMBER: 198320076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not secure sharp items or toxins in locked area, LPA Cifuentes found a pair of scissors in an unlocked drawer in facility bathroom and cleaning products and detergents outside and in an unlocked cabinet. This poses an immediate safety risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Facility staff secured scissors immediatly and moved cleaning products and detergents to garage. Licensee will get a lock for cabinet in laundry room to secure toxins. POC will be sent to LPA via fax by 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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