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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320076
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:51:55 PM

Document Has Been Signed on 04/09/2024 03:51 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:STERLING SENIOR COMMUNITY VFACILITY NUMBER:
198320076
ADMINISTRATOR/
DIRECTOR:
NAREZ, ALBERTO PIMENTELFACILITY TYPE:
740
ADDRESS:1200 W 226THTELEPHONE:
(714) 891-0088
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 6CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:32 AM
MET WITH:Caregiver Jo-Ann RitoTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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On 04/09/24 at 8:32 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Jo-Ann Rito.

The facility is an RCFE licensed for (1) ambulatory and (5) non- ambulatory residents. Facility has a hospice waiver for 2.



The facility is a one story structure located in a residential neighborhood. It consists of the following: (6) six resident bedrooms, 2 resident 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.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 114.4F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

Knives and toxics were kept in locked storage cabinet. First Aid kit was available. A new fire extinguisher arrived 04/09/24 to replace the one in the kitchen area. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

3 staff records were reviewed, 3 out of 3 staff records had current first aid certificates and required criminal record clearances or criminal record exemptions. Two staff interviews were conducted.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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 04/09/2024 03:51 PM - It Cannot Be Edited


Created By: Regina Cloyd On 04/09/2024 at 02:28 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
MONTEREY PARK, CA 91754

FACILITY NAME: STERLING SENIOR COMMUNITY V

FACILITY NUMBER: 198320076

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for one out of three residents which poses a potential safety risk to persons in care. The facility has an approved waiver for two (2) hospice residents but the facility is currently caring for three (3) residents on hospice (Resident #1, #2, and #3). The office staff immediately emailed a letter requesting for a hospice increase to regina.cloyd@dss.ca.gov
POC Due Date: 04/16/2024
Plan of Correction
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The Licensee will request for an increase prior to accepting or retaining any hospice resident that exceeds beyond the approved hospice amount. The Licensee will ensure that its request for a hospice increase meets the Title 22 regulations and emailed regina.cloyd@dss.ca.gov prior to the 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:Ulysses Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: STERLING SENIOR COMMUNITY V
FACILITY NUMBER: 198320076
VISIT DATE: 04/09/2024
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4 resident records were reviewed and, 4 out of 4 resident records had medical assessments and needs and services plans. Two residents’ medication was reviewed. Two residents were interviewed.

Deficiencies are being cited based record review in accordance with the California Code of Regulations, Title 22, see LIC809D. The facility has an approved waiver for two (2) hospice residents but the facility is currently caring for three (3) residents on hospice. LPA Cloyd reviewed three hospice binders for Resident #1, #2, and #3. The office staff immediately emailed a letter requesting for a hospice increase to LPA Cloyd.

An exit interview was conducted, technical assistance provided, and Plans of Corrections were developed and reviewed. A copy of this report and appeal rights were discussed and left with Staff.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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