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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320308
Report Date: 08/07/2024
Date Signed: 08/07/2024 11:22:49 AM

Document Has Been Signed on 08/07/2024 11:22 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:STERLING SENIOR LIVING 3FACILITY NUMBER:
198320308
ADMINISTRATOR/
DIRECTOR:		NAREZ, ALBERTO P.FACILITY TYPE:
740
ADDRESS:23025 NICOLLE AVENUETELEPHONE:
(424) 477-5657
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 6CENSUS: 6DATE:
08/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Arnold MendozaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 08/07/24, Licensing Program Analyst (LPA) Perry Scott conducted a case management inspection visit at this facility. LPA met with Arnold Mendoza, Administrator and explained the purpose of the visit is in association with a complaint investigation conducted on 07/25/24 for complaint# 11-AS-20240719140342.

During the investigation visit on 07/25/24, LPA Perry Scott audited the residents file identified in the complaint and found an SIR for the complaint but could not verify that the SIR was sent to Community Care Licensing.

The licensee is being cited with Title 22 Reporting Requirements 87211(a)(B)(D).

Based on interviews, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8 by not reporting the incident to Community Care Licensing.

A deficiency was issued.

An exit interview was conducted with Arnold Mendoza, Administrator; and copy of this report and appeal rights were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 08/07/2024 11:22 AM - It Cannot Be Edited


Created By: Perry Scott On 08/07/2024 at 06:52 AM
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 LIVING 3
FACILITY NUMBER: 198320308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2024
Section Cited
CCR
87211(a)(B)(D)

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87211(a)(B)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident... This requirement is not met as evidenced by:
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Licensee/Administrator shall read Title 22, Section 87211 “Reporting Requirements” and send a written statement to CCLD that you have read and understand this section and report all resident's incidents in the future. Written statement must be submitted to LPA Perry Scott at email perry.scott@dss.ca.gov by POC due date 08/14/2024.
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Based on records and interviews, the facility failed to submit a written report to Licensing for resident R1 who sustained multiple unexplained injuries while in care. This violation poses a potential health, safety, or personal rights 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:Janae Hammond
LICENSING EVALUATOR NAME:Perry Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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