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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320308
Report Date: 11/15/2023
Date Signed: 11/16/2023 11:03:16 AM

Document Has Been Signed on 11/16/2023 11:03 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:STERLING SENIOR LIVING 3FACILITY NUMBER:
198320308
ADMINISTRATOR:NAREZ, ALBERTO P.FACILITY TYPE:
740
ADDRESS:23025 NICOLLE AVENUETELEPHONE:
(424) 477-5657
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 4DATE:
11/15/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Kian Pascual TIME COMPLETED:
05:35 PM
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On 11/15/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Plan of Correction (POC) and was met by assistant administrator Kian Pascual. The purpose of the visit is to follow-up on the POC that was due on 10/26/23. The facility requested for an extension and was granted with a new POC date of 11/05/23. On 10/05/23, an annual visit was conducted and facility was cited for:
DEFICIENCIES:
  • 87608(5)(B) Postural Support: non-authorized full bed rails for resident #3 – Type B (corrected 11/15/23)
  • 87309(a)(1) Disinfectants/Toxic Cleaning Solutions: unsecured/unlocked bathroom #2 cabinet – Type A (corrected)
  • 87303(a) Room #3 window blinds: Broken shades – Type B (corrected)
  • 87303(a) Room #4 End Table missing drawer – Type B (corrected)
  • Administrators Certificate: Expired for Staff #1 – Type B (not cleared)
  • 87411(c)(1) No current CPR/First Aid certificates - staff #1 and #5 - Type B (corrected)
  • 87705(5)) Resident 4: No current medical and appraisal assessment for resident with Dementia – Type (not cleared)
  • 87309(b) Medicines required refrigeration not stored properly - Type A (corrected)
  • 87415(a) No night supervision - No night shift staff after 8pm - Type B (corrected 11/15/23)
  • 1569.695(c) No quarterly emergency drills conducted/documented - Type B (not cleared)
  • 87465(d) No documentation/record keeping of PRN for resident #4 - Type B (corrected 11/15/23)
  • 87465(d)(3) Prescribed medications and PRN not included in (MAR) - Type B (corrected 11/15/23)
  • 87405(b)(2) Administrator's Qualification: Failed to conform to applicable rules and regulations, which resulted to multiple citations. - Type B (not cleared)
The licensee is being cited civil penalties for violations that have not been cleared as of 11/15/23.
An exit interview conducted with Kian Pascual and a copy of the report is provided.
Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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