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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005704
Report Date: 03/20/2024
Date Signed: 03/20/2024 02:31:54 PM

Document Has Been Signed on 03/20/2024 02:31 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 4FACILITY NUMBER:
306005704
ADMINISTRATOR:MICHELLE KELLOGGFACILITY TYPE:
740
ADDRESS:150 N WHEELER STREETTELEPHONE:
(714) 912-3004
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 5DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Ruben Guzman-CaregiverTIME COMPLETED:
02:46 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Ruben Guzman. Administrator (AD) Alberto Pimentel was notified by caregiver Guzman via telephone.

For today’s visit, LPA observed a total of 5 residents in care and 2 staff members on duty.

LPA observed the Administrator's Certificate for facility AD Alberto Pimentel which expires on 04/08/2025.

LPA Ramirez toured the interior and exterior portions of the facility with caregiver Guzman. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 4 may be on hospice and 1 bedridden. For this visit, there are a total of 5 residents in care. There are a total of 6 bedrooms, of which 5 are private resident bedrooms, and 1 private bedroom for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 111.5-116.9 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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 03/20/2024 02:31 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 03/20/2024 at 01:55 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 4
FACILITY NUMBER: 306005704

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee to provide an updated documentation of the quartely drills to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STERLING SENIOR COMMUNITY 4
FACILITY NUMBER: 306005704
VISIT DATE: 03/20/2024
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LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the main entrance hallway. Facility had back-up emergency food and water supply, located in the garage. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded patio and sitting area, and the grounds were free of any hazards. There is 1 gate in the backyard, which is self-closing and self-latching. No bodies of water were observed.

LPA reviewed five resident files and two staff files. LPA interviewed residents and staff present.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with staff representative.

A copy of this report was provided at the time of exit.

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

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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