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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320076
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:57:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20231211141225
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: 5DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:ARNOLD MENDOZATIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 12/12/2023 at 9:10 AM, Licensing program analyst (LPA) Lourdes Montoya conducted an initial 10-day complaint visit to this facility to investigate the allegation mentioned above. LPA met with House Manager Arnold Mendoza and spoke with Administrator Alberto Pimentel via telephone. LPA explained the purpose of today’s visit. Administrator Alberto arrived at 3:15 PM and joined the visit. LPA observed four residents present during the visit and one resident is in the hospital.

The investigation consisted of the following: LPA Montoya toured the facility. LPA obtained copies of the following: Staff roster, resident roster, staff records and five residents’ (R1-R5) service records and other pertinent records. LPA interviewed two staff (S1-S2). LPA attempted to interview all four residents (R1-R4), but they all refused the interview.

Report continued in LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20231211141225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: STERLING SENIOR COMMUNITY V
FACILITY NUMBER: 198320076
VISIT DATE: 12/12/2023
NARRATIVE
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The investigation revealed the following:

Allegation: Facility is in disrepair.

On 12/12/2023, LPA observed one loose interior door casing in resident bedroom #2; toilet bowl not properly working and an inoperable door bell. LPA Montoya interviewed two staff (S1 and S2). Both S1 and S2 confirmed that the door bell has not been working for over a week and the toilet has not been working for about a month. S1 and S2 claimed they did not observe the loose interior door casing.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; Therefore, the above allegation, "Facility is in disrepair” is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Health and Safety Code), the following deficiency has been observed and citation issued (ref. LIC 9099D).

Exit interview was conducted and a copy of the report and appeal rights were provided to House Manager Arnold Mendoza.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20231211141225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: STERLING SENIOR COMMUNITY V
FACILITY NUMBER: 198320076
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87303(a)
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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.

This requirement is not met as evidenced by:
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Licensee shall ensure the facility is maintained in good repair at all times. House Manager agreed to reinstall the interior door casing, fix the toilet bowl and the door bell. Proof of correction shall be submitted to CCLD via email to LPA Montoya at lourdes.montoya@dss.ca.gov by the POC due date, 12/29/2023.
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LPA observed one loose interior door casing in resident bedroom #2; toilet bowl not properly working and inoperable door bell. This poses a potential health, safety and/or personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
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