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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005632
Report Date: 12/12/2023
Date Signed: 12/12/2023 06:58:54 PM

Document Has Been Signed on 12/12/2023 06:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Kian PascualTIME COMPLETED:
07:00 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Deficiencies inspection at the facility today due to deficiencies observed during the investigation of complaint control # 22-AS-20231211123251. LPA met with administrator Kian Pascual and explained the reason for the report.

During the inspection, LPA Cortez observed the following deficiencies.
At 9:47 a.m., the LPA observed prescribed Tobramycin-dexameth Ophth medication, earwax removal aid and Benadryl itch stopping gel in resident room #1 unsecured and accessible to residents in care.
At 10:01 a.m., the LPA observed MAREE keratin & vitamins superfood hair complex leave-in serum capsules, triple antibiotic ointment and a pair of scissors in an unlocked staff room.
At 10:05 a.m., the LPA observed prescribed Triamcinolone .1% cream medication, Calmoseptine ointment, and Theraworx relief for muscle cramps foam in resident room #6 unsecured and accessible to residents.
At 10:06 a.m., the LPA observed prescribed Triamcinolone 0.1% ointment medication, Neosporin, Tinacin athletes foot cream, refresh tears in resident room #7 unsecured and accessible to residents in care.
At 10:14 a.m., the LPA observed Severe Cold & Flu maximum strength medication, and prescribed Debrox earwax removal kit inside the kitchen refrigerator unsecured and accessible to residents in care.
At 10:20 a.m., the LPA observed prescribed Dorzolamide-Timolol eye drops, prescribed Latanoprost 0.005% solution, and Cranberry liquid herbal supplement inside the unlocked garage unsecured and accessible to residents in care. The LPA also observed several grooming and hygiene items throughout the facility. The facility serves residents with dementia who are at risk if they have direct access to personal grooming and hygiene items per their Physicians report.
Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2023 06:58 PM - It Cannot Be Edited


Created By: Esther Cortez On 12/12/2023 at 06:11 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 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
87705(f)(2)

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87705 (f)(2) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... vitamins....This requirement is not met as evidenced by:
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Upon observation staff removed all medications, and locked both staff room and garage. POC has been met.
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Based on observation, the license did not comply with the section cited above as the LPA observed medications in the facility accessible to residents which poses an immediate health and safety risk to residents in care.
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Type A
12/22/2023
Section Cited
CCR87705(g)(1)

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87705(g)(1) Care of Persons with Dementia. … Residents with dementia shall be allowed to keep personal grooming and hygiene items … unless there is evidence to substantiate that the resident cannot safely manage the items.
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The Administrator agreed to the following:
1. Secure the items by the end of the day. Inform CCL when this has taken place
2. Conduct an in-service training with care staff, regarding items that shall be inaccessible to residents with dementia.
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This requirement is not met as evidenced by:
Based on observation and record review, the licensee did not comply in the section cited above for two residents (R1,R4), which poses an immediate health and safety risk to resident in care.
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Submit sign-in sheet no later than 12/22/2023. Submit POC to CCLASCPWoodlandHillRO@dss.ca.gov,
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: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


LIC809 (FAS) - (06/04)
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