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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005632
Report Date: 12/12/2023
Date Signed: 12/12/2023 07:00:13 PM

Substantiated


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 Esther Cortez
COMPLAINT CONTROL NUMBER: 22-AS-20231211123251
FACILITY NAME:STERLING SENIOR COMMUNITY IIFACILITY NUMBER:
306005632
ADMINISTRATOR:PASCUAL, KIANFACILITY TYPE:
740
ADDRESS:19112 PAPUA LANETELEPHONE:
(714) 357-1377
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kian PascualTIME COMPLETED:
07:00 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 resident’s records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez conducted a 10-Day initial complaint visit to the facility at 9:20 a.m. The LPA was greeted by House Manager Irvin Ortiz and the reason for the visit was explained. Administrator Kian M. Pascual arrived shortly.

The LPA toured the physical plant with House Manager Irvin, obtained pertinent documents, conducted a file review, conducted a medication audit, interviewed one (1) resident, one residents family member, and one (1) staff from 9:20 a.m to 5:30 p.m.

Facility is in disrepair.
On the allegation Facility is in disrepair, it is the reporting party’s concern that the facility is in despair. To investigate the allegation, the LPA conducted a physical plant tour with the administrator at 9:46 a.m
Report will continue on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
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 7
Control Number 22-AS-20231211123251
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 II
FACILITY NUMBER: 306005632
VISIT DATE: 12/12/2023
NARRATIVE
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During the tour, the LPA observed missing blinds in resident rooms #3, #6, #7 and in the living room. At 9:50 a.m. the LPA observed the restroom in room #2 to be unkept with the resident’s toilet being soiled, and stains observed on the cabinet doors of the sink and residue stains on the sink. At 9:53 a.m. the LPA observed the resident’s restroom in room #3 to be unkempt with urine at the feet of the toilet and the room smelled of urine. At 10:13 a.m. during the kitchen physical tour the LPA observed the following food items expired: 1 half finished gallon of cranberry juice with best before date of 26 NOV23 and 7 Jars of Traditional Alfredo sauce with the best if used by SEP-07-23. At 10:21 a.m. the LPA observed the additional refrigerator in the garage with yellow stains on the door. Based on observations, there is sufficient evidence to support the above allegation of Facility is in disrepair occurred. Therefore, the allegation is deemed Substantiated at this time.

Facility staff failed to properly administer resident’s medications and Facility failed to maintain complete and accurate resident records.
On the allegations, of Facility staff failed to properly administer resident’s medications and Facility failed to maintain complete and accurate resident records, it is the reporting party’s concern that the facility has medication errors and incomplete resident records. To investigate the allegations, the LPA conducted a medication audit for three (3) out of six (6) residents at 1:18 p.m. The medications were stored in a locked cabinet in the dining room. During Resident #1 (R#1's) audit, the LPA observed Omeprazole not properly documented on the centrally stored medication and destruction record (CSMDR), as the Instructions did not match the prescription label. On the CSMDR, the instructions were documented as follows: take 1 cap po bid. When asked, staff revealed that bid meant twice a day, however the medications prescription label instructions read as follows: Take 1 capsule by mouth once daily before breakfast. The Medication Administration Record (MAR) reflects the medication only being given once daily, however when staff did a medication count of Omeprazole, the count was off, with three more capsules in the bottle than needed based on the start date. During R1’s audit, the LPA also observed Ezetimibe not properly documented on the CSMDR with the wrong expiration date and prescription number as the bottle did not have a prescription label and was an over-the-counter medication. The LPA also observed R1’s Losartan not properly documented on the CSMDR as the expiration date did not match the prescription label.

Report will continue on LIC9099-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
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: 2 of 7
Control Number 22-AS-20231211123251
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 II
FACILITY NUMBER: 306005632
VISIT DATE: 12/12/2023
NARRATIVE
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 During Resident #3’s (R3) audit, the LPA observed a bottle of Multivitamin Men 50+ without a prescription and not documented on the CSMDR. The LPA also observed R3’s Latanoprost 0.005% solution and Timolol Maleate 0.5% solution not documented on the CSMDR. Based on the medication audit and medication records review, there is sufficient evidence to support the above allegation of Facility staff failed to properly administer resident’s medications and Facility failed to maintain complete and accurate resident records. Therefore, the above allegations are deemed Substantiated at this time.

Pursuant to Title 22 Division 6 of the California Code of Regulations the facility was in violation as follows (see 809-D): Exit interview conducted with administrator Kian Pascual. Today's reports and appeal rights were reviewed and issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
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 7
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 Esther Cortez
COMPLAINT CONTROL NUMBER: 22-AS-20231211123251

FACILITY NAME:STERLING SENIOR COMMUNITY IIFACILITY NUMBER:
306005632
ADMINISTRATOR:PASCUAL, KIANFACILITY TYPE:
740
ADDRESS:19112 PAPUA LANETELEPHONE:
(714) 357-1377
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kian PascualTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Facility is not adequately staffed.
Facility failed to maintain a complete and accurate staff records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez conducted a 10-Day initial complaint visit to the facility at 9:20 a.m. The LPA was greeted by House Manager Irvin Ortiz and the reason for the visit was explained. Administrator Kian M. Pascual arrived shortly.

The LPA toured the physical plant with House Manager Irvin, obtained pertinent documents, conducted a file review, conducted a medication audit, interviewed one (1) resident, one residents family member, and one (1) staff from 9:20 a.m to 4:30 p.m.

Facility is not adequately staffed.
Regarding the allegation: Facility is not adequately staffed, the LPA conducted interviews and file review to investigate the allegation.
Report will continue on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
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 7
Control Number 22-AS-20231211123251
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 II
FACILITY NUMBER: 306005632
VISIT DATE: 12/12/2023
NARRATIVE
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The LPA reviewed the facility schedule and observed two (2) to three (3) staff members on schedule during the morning/day shift (8:00 a.m-8:00 p.m.), and one staff member on schedule during the night shift (8:00 p.m.-8:00 a.m.) to take care of six residents. The LPA also observed an on-call staff on the schedule. When the LPA arrived for today’s visit the LPA observed two staff present caring for six residents. Staff were observed by the LPA to be taking care of the residents and assisting the residents every time the residents would call throughout the visit. During today’s visit the LPA also interviewed Resident #3’s (R3) family member. R3’s family members interview revealed that in combination with their daughter, they come to visit R3 around five (5) times a week and that there’s always at least two to three staff on shift. R3’s family member also stated that staff is “always very responsive” and that they have no concerns regarding the care R3 receives. Staff interviewed (Staff #1) revealed that there’s always two staff working during the morning/day shift and one staff during the night shift. S1 also revealed that if night shift staff needs assistance, they can call for assistance to the staff that lives in the facility by knocking on their door. The LPA also interviewed one (1) resident (Resident #2) to investigate the allegation, and R2’s interview revealed that they do not require assistance from the staff. Based on interviews, observation and file review, the allegation Facility is not adequately staffed is deemed unsubstantiated at this time.

Facility failed to maintain a complete and accurate staff records.
Regarding the allegation: Facility failed to maintain a complete and accurate staff records, the LPA conducted a file review to investigate the allegation. The LPA reviewed five (5) out of ten (10) staff files. The LPA reviewed five staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid/CPR cards. All files were complete. Based on file review, Facility failed to maintain a complete and accurate staff records is deemed unsubstantiated at this time.

Exit interview conducted and report issued to Administrator Kian Pascual.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
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 7
Control Number 22-AS-20231211123251
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 II
FACILITY NUMBER: 306005632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation 87303 (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by;
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Upon observation staff cleaned residents restrooms. The administrator has agreed to replace all missing blinds and complete a food audit and submit photos or self certification to LPA by 12/22/23..
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Based on observation, the licensee did not comply with the section cited above as the three resident rooms and the living room were missing window blinds, restrooms were not clean and sanitary and facility had expired food which poses a potential health and safety risk to residents in care.
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Type B
12/22/2023
Section Cited
CCR
87465(h)(6)
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Type B 87465 Incidental Medical and Dental Care (h) (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:…… This requirement is not met as evidenced by;
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Administrator will update the centrally stored to reflect medcaiton not recored. Administrator will conduct staff training on medications and submit proof to LPA by 12/22/23.
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Based on observations and record review, the licensee did not comply with the section cited above as the licensee failed properly document R1 and R3’s medications on the CSMDR which poses a potential health and safety risk to residents 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: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
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: 6 of 7
Control Number 22-AS-20231211123251
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 II
FACILITY NUMBER: 306005632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2023
Section Cited
CCR
87465(a)(4)
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Type A 87465 Incidental Medical and Dental Care(a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by;
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Adminastrator agree to provide medication training with all staff who assisting residents with medications. Administrator will send the LPA a notice of when training is schedule by 12/13/23 and proof that training has been completed no later than 12/22/23.
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Based on observation, the licensee did not comply with the section cited above as based on a medication audit and record review R1 did not receive there medication as prescribed which poses an immediate health and safety risk to R1 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: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
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: 7 of 7