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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320308
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:53:35 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, 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
12/11/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231211140912
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: 3DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
08:09 AM
MET WITH:Albert Narez, LicenseeTIME COMPLETED:
04:31 PM
ALLEGATION(S):
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Facility staff failed to properly administer resident’s medications.
Facility failed to maintain complete and accurate staff records.
INVESTIGATION FINDINGS:
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On 12/12/23 Licensing Program Analyst (LPA) Mario Leon arrived at the above-mentioned facility at 8:09AM and conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Bennie Ballon, Caregiver (S3), and later by Arnold Mendoza, Administrator (S2), and Albert Pimental Narez, Licensee (S1). Both S3 and LPA toured the facility.
The investigation consisted of the following:
On 12/12/23 LPA requested and reviewed facility documents and toured the facility. LPA interviewed two (2) out of three (3) residents and two (2) out of seven (7) staff.

The investigation revealed the following:
Regarding the allegation: "Facility staff failed to properly administer resident’s medications.". LPA interviewed two (2) staff (S1,S3). All staff have denied the allegation. LPA interviewed two (2) residents (R1-R2). One (1) out of two (2) residents have agreed with the allegation.
Report Continues, see LIC9099C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2023
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 5
Control Number 11-AS-20231211140912
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 LIVING 3
FACILITY NUMBER: 198320308
VISIT DATE: 12/12/2023
NARRATIVE
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Record reviews revealed, through the Medication Admission Record, that on 12/04/23 and 12/06/23 all residents were not provided any of their medications. Furthermore, there were no other marking in the Vital Signs - 2023 book marking any record of dosages of medications, which are centrally stored, maintained by the facility.
Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

Regarding the allegation: "Facility failed to maintain complete and accurate staff records.". LPA interviewed two (2) staff (S1, S3). One staff member was unaware of the allegation while one disagreed with the allegation.
Record reviews revealed that one (1) staff member's CPR certificate was not present, nor on file, at the above-mentioned facility. The CPR certificate was later provided, renewed on 12/12/2023.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.

There have been two (2) citations provided, please see LIC9099D.

An exit interview was held with S3, Bennie Ballon, and a copy of this report and appeal rights have been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20231211140912
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 LIVING 3
FACILITY NUMBER: 198320308
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical..Care (a) A plan for incidental medical..care shall be..by each facility. The plan shall encourage routine medical..care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by..the Department,
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LPA and Licensee have agreed that the E-Mar will also be printed in the MAR book. This way, for those staff who have not yet been trained at how to record medications electronically, staff will still be able to record the medication provided and number of dosages for residents at the facility.
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a record of dosages which are centrally stored shall be maintained by the facility.

This has not been met as evidenced by:
LPA observed 12/04/23 and 12/06/23 without medications prescribed by physician's order recorded as written above.
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Type B
12/12/2023
Section Cited
CCR
87412(a)
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87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information.
This has not been met as evidenced by:
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LPA and Licensee have agreed that Licensee will stay aware of all required certification(s) for staff to stay in compliance. Licensee will review staff folders to make sure all staff will stay in complaince for future State Licensing visits and to avoid future citations.
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Based on LPA's observations, the Licensee's current CPR certificate expired 12/02/23. Licensee later provided CPR certificate, updated 12/12/23.
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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: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
12/11/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231211140912

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:3CENSUS: 3DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
08:09 AM
MET WITH:Albert Narez, LicenseeTIME COMPLETED:
04:31 PM
ALLEGATION(S):
1
2
3
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5
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Facility is in disrepair.
Facility is not adequately staffed.
Facility failed to maintain a complete and accurate resident’s records.
INVESTIGATION FINDINGS:
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On 12/12/23 Licensing Program Analyst (LPA) Mario Leon arrived at the above-mentioned facility at 8:09AM and LPA conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Bennie Ballon, Caregiver (S3) and later by Arnold Mendoza, Administrator (S2) and Albert Pimental Narez, Licensee (S1). Both S3 and LPA toured the facility.
The investigation consisted of the following:
On 12/12/23 LPA requested and reviewed facility documents and toured the facility. LPA interviewed two (2) out of three (3) residents and two (2) out of seven (7) staff.
The investigation revealed the following:
Regarding the allegation: "Facility is in disrepair.". LPA interviewed two (2) staff (S1, S3). All staff have denied the allegation. LPA interviewed two (2) residents (R1-R2). One (1) out of two (2) residents have agreed with the allegation.

Report continues, see LIC9099-C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20231211140912
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 LIVING 3
FACILITY NUMBER: 198320308
VISIT DATE: 12/12/2023
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation: "Facility is not adequately staffed.". LPA interviewed two (2) staff (S1, S3). All staff have denied the allegation. LPA interviewed two (2) residents (R1-R2). Two (2) out of two (2) have denied the allegation.

Record reviews revealed that staff roster (LIC500) was later provided, as requested, dated 11/10/2023.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.



Regarding the allegation: "Facility failed to maintain a complete and accurate resident’s records.". LPA interviewed two (2) staff (S1, S3). All staff have denied the allegation. LPA interviewed two (2) residents (R1-R2). Two (2) out of two (2) residents have denied the allegation.

Record reviews revealed that all three (3) residents had appropriate resident records on file.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

There have been no deficiencies cited.

An exit interview was held with S3, Bennie Ballon, and a copy of this report has been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

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

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5