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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005517
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:48:09 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/08/2024 04:48 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:STERLING SENIOR LIVING 2FACILITY NUMBER:
306005517
ADMINISTRATOR/
DIRECTOR:		JEREMIAS FILIOFACILITY TYPE:
740
ADDRESS:9608 PUFFIN AVETELEPHONE:
(714) 357-1377
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:49 PM
MET WITH:Jeremias Filo, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:57 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Administrator (AD) Jeremias Filio. LPA met with (AD) Filio and discussed purpose of today's visit.

This is a Residential Care Facility for the Elderly, licensed to provide services to age range 60 and over, approved for capacity of (6) residents; 1 bedridden and 5 non-ambulatory residents and has a Hospice waiver approved for 6 hospice residents. There are currently six (6) resident in care at this time, of which (1) one is receiving hospice care services.

AD Jeremias Filio has an Administrator certificate with expiration date of March 10, 2024 indicating he completed the renewal February 26, 2024 and waiting to receive renewal certificate. AD Filio agreed to submit new certificate to CCLD upon receipt.

LPA along with (AD) Filio toured the interior and exterior of the facility. During today's inspection tour, LPA observed 2 of 4 Residents in the living room with staff supervision and 4 of 6 residents in their bedrooms resting. LPA Quiroz interacted and interviewed with caregivers and residents during today's visit.

LPA inspected resident's bedrooms and bathrooms. The water temperature in resident's bathrooms were recorded to be within normal limits. LPA inspected resident's bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be 74 degrees Fahrenheit. LPA observed the emergency and disaster and evacuation plan. Fire extinguisher observed last serviced on March 2, 2024. LPA observed functional and operational washer and dryer in the garage area. Medications, sharps and disinfectants were observed to be locked and secured. LPA toured the outside of the facility and observed seating and shaded area in the backyard for residents and visitor's enjoyment.

CONTINUED ON NEXT LIC 809-C PAGE...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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 05/08/2024 04:48 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 05/08/2024 at 04:11 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STERLING SENIOR LIVING 2
FACILITY NUMBER: 306005517

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
87555(b)(8)(23)(28)

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General Food Service Requirements 87555(b)(8)(23)(28)-(b)The following food service requirements shall apply: (8) All food shall be of good quality… (23)All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause CONT
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AD Filio will provide training on CCR 87555 Food Service Requirements to all staff identified on LIC 500, purchase food containers and develop plan/log on how staff will monitor food freshness in refrigerator and submit proof of training to CCLD by 5/10/2024.
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food infections or food intoxications shall be stored in covered containers at appropriate temperatures. (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement was not met as evidenced by:
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On or about 3:35pm while inspecting the kitchen area, LPA Quiroz observed multiple food items not labeled without covers and mutiple expired food items with expiration dates ranging between February 3, 2023- March 3, 2024. This was verified by AD Filio.
Type B
05/10/2024
Section Cited
CCR87412(f)

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Personnel Records: 87412(f)-All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be CONT
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AD Filio will read and understand CCR 87412 and submit proof of understanding and Staff#7 personnel file for review to CCLD by 5/10/24.
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subject to the following requirements:This requirement was not met as evidenced by Staff #7 personnel file was not readily available for licensing review on today's date.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STERLING SENIOR LIVING 2
FACILITY NUMBER: 306005517
VISIT DATE: 05/08/2024
NARRATIVE
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CONTINUED...On or about 3:35pm while inspecting the kitchen area, LPA Quiroz observed pineapple with fuzzy green in color on pineapple in container without a cover appearing to look like mold, unlabeled food in zip lock bags with no dates, multiple food items not labeled without covers and the following expired food with expiration dates ranging between February 3, 2023- March 3, 2024: ranch dressing, tartar sauce, lasagna, pears, apples, melon, activia yogurts and snack vanilla and chocolate puddings. AD Filio verified observations and discarded expired food during today’s visit indicating “Tomorrow is grocery day.” (SEE LIC 809-D)

Facility has supply of emergency food, limited water and PPE in the garage area readily available for staff and residents in care. LPA verified that fire/disaster drills are conducted at least quarterly. The last fire drill was conducted on December 12, 2023.

LPA reviewed 6 of 6 resident records and 6 of 7 personnel files.

Citations issued during today's visit.

During today's visit, LPA provided Consultation on Title 22 and Infection control. An exit interview was conducted with (AD) Jeremias Filio, and a copy of this report, LIC 809-D pages and Appeal Rights were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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