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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320076
Report Date: 12/13/2023
Date Signed: 12/13/2023 12:49:50 PM

Document Has Been Signed on 12/13/2023 12:49 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:
12/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:ARNOLD MENDOZATIME COMPLETED:
01:00 PM
NARRATIVE
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On 12/13/2023 at 9:00 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 on 12/12/2023, LPA Montoya observed the following deficiency:

LPA Lourdes Montoya observed during records review that R1's Appraisal/Needs and Services Plan dated 7/1/2021 is identical to R1's Appraisal/Needs and Services Plan dated 1/21/2023. LPA observed the type written date (7/1/2021) on the appraisal was erased with a white out and the date was changed with a hand written date (1/21/2023). Two staff (S1-S2) acknowledged that the appraisal dated 7/21/2021 is a photo copy of the appraisal dated 1/21/2023. S3 on the other hand argued that since R1 did not have any medical change, a photo copy of R1's 2021 appraisal is acceptable to make R1's appraisal current.

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: 12/13/2023
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2023 12:49 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 12/13/2023 at 12:12 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: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87405(d)(1)(2)

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87405 Administrator - Qualifications and Duties

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement was not met as evidenced by:
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The administrator shall self-certify understanding of the section cited herein and shall always comply. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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On 12/12/2023, LPA Lourdes Montoya observed during records review that R1's Appraisal/Needs and Services Plan dated 7/1/2021 is identical to R1's Appraisal/Needs and Services Plan dated 1/21/2023. LPA observed the typed written date (7/1/2021) was erased with a white out and the date was changed with a hand written date (1/21/2023). Two staff (S1-S2) acknowledged that the appraisal dated 7/21/2021 is a photo copy of the appraisal dated 1/21/2023. S3 on the other hand argued that since R1 did not have any medical change, a photo copy of R1's 2021 appraisal is acceptable to make R1's appraisal current. This poses a potential health, safety and/or personal right 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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