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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005710
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:54:14 PM

Document Has Been Signed on 12/12/2023 02:54 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
Lookup Error,
, CA
FACILITY NAME:STERLING SENIOR COMMUNITY IIIFACILITY NUMBER:
306005710
ADMINISTRATOR:NAREZ, ALBERT PIMENTELFACILITY TYPE:
740
ADDRESS:14631 SHINKLE CIRCLETELEPHONE:
(657) 400-9561
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 6DATE:
12/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Administrator Albert NarezTIME COMPLETED:
03:00 PM
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CASE MANAGEMENT FINDINGS:

LPA Ramirez conducted case management deficiencies visit on 12/12/23, stemming from initial complaint investigation conducted on 12/12/23. Upon entering facility, LPA Ramirez observed staff#1 (S1) washing dishes in facility kitchen and cleaning up kitchen. LPA Ramirez observed four (4) residents seated living room area and one (1) resident seated at dining room table. During record review, LPA Ramirez discovered S1 does not have criminal record clearance or criminal record exemption. According to staff interviews, S1 has only been in the facility today (12/12/23). LPA Ramirez will issue Civil Penalty Assessment (LIC 421 BG) of $100 for violation and deficiency.

Exit interview was conducted and a copy of this report, 809-D, LIC 421BG and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
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 02:54 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 12/12/2023 at 02:12 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
,
, CA

FACILITY NAME: STERLING SENIOR COMMUNITY III
FACILITY NUMBER: 306005710

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
1569.17(b)(D)

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1569.17 Fingerprints and criminal records of individuals in contact with clients;
(b) In addition to the applicant, the provisions of this section shall apply to criminal record clearances and exemptions for the following persons:
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Licensee will not allow S1 back into the facility until S1 has criminal clearance or exemption. Licensee will certify understanding of regulation (1569.17(b)(D) by 12/13/23.
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(D) Any staff person, volunteer, or employee who has contact with the clients.

This requirement was not as evidence by:
S1 was observed in facility washing dishes and coming into contact with residents without criminal clearance or exemption.
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
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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