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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005630
Report Date: 12/13/2023
Date Signed: 12/26/2023 09:26:10 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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 Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231211122154
FACILITY NAME:STERLING SENIOR COMMUNITY IFACILITY NUMBER:
306005630
ADMINISTRATOR:PASCUAL, KIANFACILITY TYPE:
740
ADDRESS:6081 IVORY CIRCLETELEPHONE:
(714) 357-1377
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 5DATE:
12/13/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Kian PascualTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is in disrepair.
Facility staff failed to properly administer resident’s medications.
Facility failed to maintain a complete and accurate staff records.
Facility failed to maintain a complete and accurate resident’s records.
INVESTIGATION FINDINGS:
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This is an amended copy of the report previously issued on 12/13/2023. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same.

On 12/13/23, at 9:05am, Licensing Program Analyst (LPA) Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by caregiver Ireland Torren (S1). The administrator was called and arrived at 10:25am. LPA asked for the census, staff, and resident files.

Regarding the allegation: Facility failed to maintain a complete and accurate resident’s records. It is being alleged that the resident records were not complete and accurate. LPA observed two staff present. LPA asked how many staff are currently working and the staff stated two staff are presently working. The resident files were reviewed for all five (5) residents. All five (5) residents had the identification/emergency-601, admission agreement, physician report, telecommunications, medical consent,
9099-C-continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
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 22-AS-20231211122154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STERLING SENIOR COMMUNITY I
FACILITY NUMBER: 306005630
VISIT DATE: 12/13/2023
NARRATIVE
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This is an amended copy of the report previously issued on 12/13/2023. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same.

preplacement/resident appraisal, Appraisal needs and services plan, personal rights of
the residents, physician progress reports, consent forms. LPA did not observe the resident records to be incomplete and inaccurate. The LPA attempted to interview five (5) out of five (5) residents, but due to their inability to communicate with words, that could not be completed.

Regarding the allegation: Facility failed to maintain a complete and accurate staff records. It is being alleged that the staff records were not complete and accurate.LPA reviewed all personnel record, health screening with TB test results, CPR/first aid, employee rights, statement acknowledging requirement to report suspected abuse of dependent adults and elders, criminal background and in service/training. All records were observed, reviewed and copies were obtained. The LPA did not observe the staff records to be incomplete and/or inaccurate. The LPA was able to interview four (4) staff.

Regarding the allegation: Facility is in disrepair. It’s being alleged that the physical plant is in disrepair.LPA conducted a physical plant tour of the facility at 9:45a.m. There is a total of seven (7) bedrooms. Six (6) bedrooms is used for residents (single occupancy). The resident's room was equipped with proper bedding and lighting. There is a total of three (3) bathrooms. There is also smoke detectors and carbon monoxide detectors throughout the house in working order. There is a backyard that has a shaded area and seating for all residents. During interview with staff, staff did not report any disrepair with the facility. LPA did not observe the physical plant to be in disrepair.

Regarding the allegation: Facility staff failed to properly administer resident’s medications.


LPA reviewed all five (5) resident medications and Medication Administration Records (MAR). Records were reviewed and were observed to be properly distributed according to the medication record.
The LPA observed the bubble packs to have the accurate date and were properly dispensed. The AM, PM and bedtime were administered up to/leading to 12/13/23. There was also PRN- (as needed medication) in bubble packs. The medication was labeled per resident name in separate binders, stored and locked in a cabinet inaccessible to the residents. LPA did not observe the resident medication to not be properly administered.

Based on the LPA's interviews, observations, and record reviews all four allegations above are unsubstantiated at this time. All copies of records/files were obtained.

An exit interview was conducted, no citations were issued for the four (4) above allegations, and a copy of this report was given to the administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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 Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231211122154

FACILITY NAME:STERLING SENIOR COMMUNITY IFACILITY NUMBER:
306005630
ADMINISTRATOR:PASCUAL, KIANFACILITY TYPE:
740
ADDRESS:6081 IVORY CIRCLETELEPHONE:
(714) 357-1377
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 5DATE:
12/13/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Kian PascualTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility is not adequately staffed
INVESTIGATION FINDINGS:
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This is an amended copy of the report previously issued on 12/13/2023. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same.

On 12/13/23, at 9:05am, Licensing Program Analyst (LPA) Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by caregiver Ireland Torren (S1). The administrator was called and arrived at 10:25am.

Regarding the allegation: Facility is not adequately staffed: It’s being alleged that the facility is understaffed. LPA asked how many staff are currently working at the facility and the staff stated that there are two staff presently working. Based on the record reviews, staff schedules states, they work five (5) days out of the week with working shifts from 7AM to 7PM and can choose to work over-time. There is no overnight staff, and the weekend staff also work from 7am to 7pm and can choose to work over-time.
9099-A continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20231211122154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STERLING SENIOR COMMUNITY I
FACILITY NUMBER: 306005630
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2023
Section Cited
CCR
87705(c)(4)(A)
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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia...(4)There is an adequate number of direct care...safety and health care needs… (A) In addition to... specified in Section 87415, Night Supervision, a facility with fewer than 16...at least one night staff person...This requirement is not met as evidenced by:
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The licensee/admnistrator will send the LPA an updated personnel report showing the caregivers schedule showing there is a night person on duty seven (7) days out of the week to care for residents with dementia.

POC 12/14/23
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Based on the observation, interviews and
record reviews, the licensee did not ensure one out of five staff at the facility to be on duty at night and supervise the care of the residents of dementia have which poses immediate Health, Safety or Personal Rights risks to person 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20231211122154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STERLING SENIOR COMMUNITY I
FACILITY NUMBER: 306005630
VISIT DATE: 12/13/2023
NARRATIVE
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This is an amended copy of the report previously issued on 12/13/2023. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same.

LPA spoke to the Licensee to verify how many staff are working on the weekend and overnight. Licensee stated, ‘there is no staff that work overnight. They have live-in staff in case anything goes wrong.” LPA conducted a record review which indicated resident with dementia are currently in care at the facility.

Based on LPAs observations, interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter 6), are being cited on the attached LIC-9099D.”) when there is care of residents with dementia Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty. There are currently three (3) residents out of five (5) residing at the facility with a current diagnosis of dementia.

An exit interview was conducted, citation given, appeal rights, and a copy of this report was given to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5