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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005704
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:26:51 AM

Unfounded


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 Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231211124121
FACILITY NAME:STERLING SENIOR COMMUNITY 4FACILITY NUMBER:
306005704
ADMINISTRATOR:MICHELLE KELLOGGFACILITY TYPE:
740
ADDRESS:150 N WHEELER STREETTELEPHONE:
(714) 912-3004
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 5DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Ruben Guzman-Caregiver, Alberto Pimentel-AdministratorTIME COMPLETED:
11:44 PM
ALLEGATION(S):
1
2
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9
Facility staff failed to properly administer resident’s medications.
Facility failed to maintain a complete and accurate resident’s records.
Facility failed to maintain a complete and accurate staff records.
INVESTIGATION FINDINGS:
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2
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13
Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on 12/11/23. LPA was greeted and granted entry into the facility and met with Caregiver Ruben Guzman. Administrator (AD) Alberto Pimentel was notified via telephone by caregiver Guzman. LPA explained the reason for the visit.

This agency has investigated the complaint alleging that facility staff failed to properly administer resident’s medications. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Three of four individuals interviewed denied the allegation. During the investigation LPA reviewed documents including the Monthly Medication Record dated December 2023 for Resident 1 (R1) and R2. Per Monthly Medication Record, R1 and R2 were given their medications according to the Physician's directions. During the course of the interviews with residents, Resident 1 (R1) reported that their medications are administer properly.
CONTINUED ON LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 4
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 Alvaro Ramirez Jr.
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20231211124121

FACILITY NAME:STERLING SENIOR COMMUNITY 4FACILITY NUMBER:
306005704
ADMINISTRATOR:MICHELLE KELLOGGFACILITY TYPE:
740
ADDRESS:150 N WHEELER STREETTELEPHONE:
(714) 912-3004
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 5DATE:
03/07/2024
UNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Ruben Guzman-CaregiverTIME COMPLETED:
11:44 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not adequately staffed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on 12/11/23. LPA was greeted and granted entry into the facility and met with Caregiver Ruben Guzman. Administrator (AD) Alberto Pimentel was notified via telephone by caregiver Guzman. LPA explained the reason for the visit.

This agency has investigated the complaint alleging that facility is not adequately staffed. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Three of four individuals interviewed denied the allegation. During the investigation LPA reviewed documents including the Sterling Senior Community 4 Personnel Report (LIC500) dated December 2023. Per Personnel Report on average there are two caregiver from 7:00AM-7:00PM and one caregiver from 7:00PM-7:00AM for five residents in care. During the course of the interviews, AD stated that the facility is not understaffed and reported that he has caregivers on-call if needed.
CONTINUED ON LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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 4
Control Number 22-AS-20231211124121
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 4
FACILITY NUMBER: 306005704
VISIT DATE: 03/07/2024
NARRATIVE
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During the course of the interviews with staff, Staff 1 (S1) reported that they have enough staff to care for the residents and reported that he is one of two live-in caregivers.

Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED.

LPA Ramirez conducted an exit interview with facility representative, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20231211124121
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 4
FACILITY NUMBER: 306005704
VISIT DATE: 03/07/2024
NARRATIVE
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2
3
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5
6
7
8
9
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Per R1 staff do a good job and always do their best.

Regarding the allegation that facility failed to maintain a complete and accurate resident’s records, the investigation revealed the following: Three of four individuals interviewed denied the allegation. During the investigation LPA reviewed documents including the Sterling Senior Community 4 Admission Agreement for Resident 1 (R1) dated 07/12/23, for R2 dated 05/14/20, for R3 dated 08/14/23 and for R4 dated 05/11/23. The Admission Agreements for R1, R2, R3 and R4 were signed and dated the date of admission.

Regarding the allegation that facility failed to maintain a complete and accurate staff records, the investigation revealed the following: LPA reviewed documents including the Health Screening Report - Facility Personnel (LIC503) for Staff 1 (S1) dated 03/27/23 and for S2 dated 10/30/23. LPA observed that all sections on the Health Screening Report - Facility Personnel for S1 and S2 were completed, dated and signed.

Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis.

LPA Ramirez conducted an exit interview with facility representative, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4