198320308-12-9-2023-11-AS-JHAD-CZT2J9-20240124162559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320308
Report Date: 12/09/2023
Date Signed: 12/09/2023 11:25:45 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231109114136

FACILITY NAME:	STERLING SENIOR LIVING 3		FACILITY NUMBER:	198320308
ADMINISTRATOR:	NAREZ, ALBERTO P.		FACILITY TYPE:	740
ADDRESS:	23025 NICOLLE AVENUE		TELEPHONE:	(424) 477-5657
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	6	CENSUS: 3	DATE:	12/09/2023
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Arnold Mendoza		TIME COMPLETED:	10:59 AM

ALLEGATION(S):

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Staff gave resident medication not prescribed.

INVESTIGATION FINDINGS:

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On 12/09/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit at this facility. LPA was greeted by caregiver Ben Ballon, Ballon contacted administrators Arnold Mendoza and Albert Pimentel who later arrived at the facility. LPA explained the purpose of the visit was to deliver findings for the allegation mentioned above.

The investigation consisted of the following: Interviews with residents #1-#5, witnesses #1-#5, and staff #1-#4. A review of resident #1 (R1's) service records and other pertinent documents associated with this complaint. A physical tour of the facility was conducted. A collateral visit was conducted at Golden Eden II. (Evaluation Report continues LIC 9099-C)

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

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-20231109114136

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STERLING SENIOR LIVING 3	FACILITY NUMBER: 198320308
	VISIT DATE: 12/09/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff gave resident medication not prescribed.

The details of the complaint alleged staff chemically restrained resident #1 (R1) by administering a non-prescribed medication. The complainant reported sometime in October 15 through 30, 2023 a staff gave Lorazepam to (R1) during the early morning hours of 12 am – 6 am when (R1) experienced restlessness and agitation. The complainant did not observe the staff administering the Lorazepam to (R1) and that it was only information provided by another individual.

Resident #1 (R1) was admitted to this facility on 09/29/22 according to the facilities’ Identification and Emergency Information LIC 601 dated: 09/28/22. (R1) voluntarily terminated residency on 11/3/23. A review of (R1’s) Medication Administration Record (MAR) (dated: 10/01/23 – 10/31/23) of (R1’s) medications has remained consistent. The (MAR) for (R1) noted medications were taken daily, and no medications were missed or refused. There were no non-prescribed medications listed by staff identified as Lorazepam or Ativan noted on the Centrally Stored Medication and Destruction Record LIC 622 (dated: 11/08/23). There were (7) of (11) medications prescribed by (R1’s) medical physicians such as Risperidone, Sertraline, Melatonin, Trazodone, Buspirone, and Memantine all have side effects that may result in a state of being relaxed, sleepy or calmness according to the National Institute of Health (ref.NIH.gov).

On 11/15/23 between 10:01 am and 10:29 am, the Department interviewed the family representative of (R1) witness #1 (W1) who confirmed that (R1) was prescribed Lorazepam but became suspicious when (W1) was informed by a former staff that had issued Lorazepam to sedate (R1). (W1) was unable to determine the date of the alleged incident and stated that (W1) did not witness this activity only through information provided by the former staff.

On 11/15/23 between 10:30 am – 12:00 pm, the Department interviewed (3) out of (3) staff #2-#4 (S2-S4) claimed to not know any staff providing non-prescribed medications to any of the residents. (S2-S4) claimed only what is listed on the (MAR) or (LIC 622) is administered to residents.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20231109114136

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STERLING SENIOR LIVING 3	FACILITY NUMBER: 198320308
	VISIT DATE: 12/09/2023

NARRATIVE

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On 11/15/23 between 12:00 pm – 12:22 pm, the Department interviewed the former staff witness #2 (W2) the informant to (W1) with this information. (W2) claimed to have been informed by staff #1(S1) that Lorazepam was issued to (R1) when (R1) was agitated and restless during early morning hours. (W2) stated no other witnesses overheard this conversation and were unable to verify the date or time when given the information from (S1). (W2) confirms that information was only given to (W1) and no other individuals were made aware of the matter.

On 11/15/23 between 1:02 pm and 1:23 pm, the Department interviewed staff #1 (S1) who denied this alleged act and claimed this accusation was false. (S1) stated no nonprescribed medications such as Lorazepam or Ativan were ever given to (R1). (S1) denied ever informing any individuals of this matter. (S1) claimed that only residents in hospice care are prescribed such medication. (S1) claimed to be fully trained in administering or delivering prescription medications and follows what is on the listed on (LIC 622).

On 11/15/23 between 2:00 pm – 2:47 pm, the Department interviewed (2) out of (4) residents #2-#3 (R2-R3) who reported needing assistance with medication management and have not encountered issues nor have been provided medications that are not prescribed by their medical physician. (R4-R5) were interviewed but were unable to fully participate in conversation due to their health conditions.

On 11/15/23 between 3:02 pm – 4:15 pm, the Department interviewed family representatives witnesses #3-#4 (W3-W4) for residents #4-#5 (R4-R5) were complimentary of the staff and reported to have no concerns for the care and supervision of residents at this facility. (W3-W4) claimed there have been no medication errors that have been witnessed or reported by any facility staff.

On 11/15/23 between 8:44 am – 9:02 am the Department interviewed facility administrator witness #5 (W5) who verified (R1) was admitted on 11/09/23 with no Lorazepam or Ativan was listed on the medication list and no refills included such medication.

On 11/15/23 between 9:03 am – 9:24 am the Department interviewed resident #1 (R1) who had no comments. (R1) was unable to fully participate in a conversation due to (R1’s) health condition.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20231109114136

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: STERLING SENIOR LIVING 3	FACILITY NUMBER: 198320308
	VISIT DATE: 12/09/2023

NARRATIVE

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The Department reviewed personnel records for staff #1 (S1) and verified that medication training was completed by staff. Biological Laboratory urine drug screening test results for (R1) conducted 10/23/23 revealed negative for Lorazepam or Ativan.

Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with Arnold Mendoza, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2023

LIC9099 (FAS) - (06/04)

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