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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320076
Report Date: 12/13/2023
Date Signed: 12/13/2023 12:45:56 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:
12/13/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ARNOLD MENDOZATIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility is not adequately staffed.
Facility failed to maintain a complete and accurate resident’s records.
INVESTIGATION FINDINGS:
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On 12/13/2023 at 9:00 AM, Licensing program analyst (LPA) Lourdes Montoya conducted a subsequent complaint visit to this facility to investigate the allegations mentioned above. LPA met with House Manager Arnold Mendoza and explained the purpose of today’s visit. LPA observed four residents present during the visit and one resident is still in the hospital.

The investigation consisted of the following: On 12/12/2023, LPA Montoya toured the facility with House Manager Arnold Mendoza. LPA obtained copies of the following: Staff roster, resident roster, thee staff records (S1-S3) 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: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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 4
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: 12/13/2023
NARRATIVE
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The investigation revealed the following:

Allegation: Facility is not adequately staffed.

On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed there are two caregivers providing care and supervision to five residents during day shift from 7:00 AM through 7:00 PM. S1 and S2 stated an awake staff is placed to work overtime when any residents pose a restless behavior. Based on interview with S1 and S2 and LPA's records review, it was revealed that four residents (R1, R2, R4 & R5) need close supervision due to their medical conditions, however S1 and S2 stated there are no awake staff during night shift. Based on LPA's observations, R5 was not present during the visit. LPA observed R1 is ambulatory and uses a walker. LPA observed R2 is bed bound and R4 walks around the facility with a walker. Based on LPA’s review of records R1 is confused, has wondering behavior and unable to leave the facility unassisted. R1’s appraisal indicates R1 is a fall risk and needs adequate supervision for safety. Based on review of the appraisals, R2 and and R4 need special observation/night supervision. R5’s appraisal show R5 has memory loss and needs adequate assistance to promote safety. Based on observations, interviews, and records review there is enough evidence to prove that above allegation is corroborated.

Allegation: Facility failed to maintain a complete and accurate resident’s records.

On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed they assumed the resident records are maintained completely and accurately. LPA reviewed records of five out of five residents (R1-R5). LPA’s records review revealed resident records are not maintained completely and accurately. LPA observed R1’s file has no current medical assessment, no weight records, no accurate appraisal, and no completed cash resources. R2’s file has no medical assessment, no weight records, no immunization records, no TB test record, no completed safeguard for cash resources and for property and/or valuables. R3 has no weight records, no completed safeguard for cash resources and

REPORT CONTINUED IN LIC 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 12/13/2023
NARRATIVE
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for property and/or valuables. R4 has no medical assessment, no weight records, no TB test, no current appraisal, unsigned personal rights, no completed safeguard for cash resources and for property and/or valuables. And R5 has no current medical assessment, no weight records, no current appraisal, no completed safeguard for cash resources and for property and/or valuables. Based on observations, interviews, and records review there is enough evidence to prove that above allegation is corroborated.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; Therefore, the above allegations, " Facility is not adequately staffed” and “Facility failed to maintain a complete and accurate resident’s records” are found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Health and Safety Code), the following deficiencies have been observed and citations 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: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87506(a)
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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement was not met as evidenced by:

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Licensee shall ensure all resident records are complete and accurate. House Manager agreed to obtain all missing resident records and shall submit copies to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 12/29/23.
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On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed they assumed the resident records are maintained completely and accurately. LPA reviewed records of five out of five residents (R1-R5). LPA’s records review revealed resident records are not maintained completely and accurately. This poses a potential health, safety, and/or personal rights risk to persons in care.
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Type B
12/29/2023
Section Cited
CCR
87705(c)(4)(A)
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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.
This requirement was not met as evidenced by:
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Licensee shall ensure there's always one aware staff during night shift to provide care and supervision to residents with dementia. Licensee shall self-certify understanding of the section cited herein and shall comply. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 12/29/23.
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On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed there are two caregivers providing care and supervision to five residents during day shift from 7:00 AM through 7:00 PM. S1 and S2 stated an awake staff is placed to work overtime at nght from 7:00 PM - 7:00 AM when any residents pose a restless behavior. Based on interview with S1 and S2 and LPA's records review, it was revealed that four residents (R1, R2, R4 & R5) need close supervision due to their medical conditions, however S1 and S2 stated there are no on-duty awake staff during night shift unless needed. This poses a potential health, safety, and/or personal rights risk to persons 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: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4