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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320076
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:53:03 PM

Document Has Been Signed on 12/12/2023 04:53 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:ARNOLD MENDOZA TIME COMPLETED:
05:00 PM
NARRATIVE
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On 12/12/2023 at 9:10 am, LPA Lourdes Montoya conducted a case management-deficiency visit at this facility. LPA Montoya met with House Manager Arnold Mendoza.

During an unrelated complaint visit, LPA Montoya observed the following deficiency:

1. LPA observed two residents (R2 & R4) use full bedrails and two residents (R3 & R5) use half bedrails. Upon review of these residents’ records, LPA did not find prescriptions for all four residents' bedrails. S1 confirmed none of them have prescriptions for bedrails.


Deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22.

Failure to correct the deficiency may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights 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
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 12/12/2023 04:53 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 12/12/2023 at 04:00 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
, 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
87608(a)(3)

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87608(a)(3) (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.

(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidenced by:
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Licensee shall ensure residents have prescriptions for postural supports. House manager agreed to consult with the residents’ family and their medical providers for the need of postural support. House Manager Mendoza shall remove the postural supports of the residents who do not have prescriptions. 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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On 12/12/2023 during an unrelated complaint visit, LPA observed two residents (R2 & R4) use full bedrails and two residents (R3 & R5) use half bedrails. Upon review of these residents’ records, LPA did no find prescriptions. S1 confirmed none of them have prescriptions for bedrails. 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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