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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006007
Report Date: 06/24/2021
Date Signed: 06/24/2021 11:49:23 AM

Document Has Been Signed on 06/24/2021 11:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:STERLING SENIOR COMMUNITY VIFACILITY NUMBER:
306006007
ADMINISTRATOR:NAREZ, ALBERTOFACILITY TYPE:
740
ADDRESS:140 N WHEELER STTELEPHONE:
(714) 538-9615
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 6DATE:
06/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Albert NarezTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA arrived at the facility, was greeted by applicant and granted entry.

An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden resident was submitted to CCL on 09/08/2020.

Structure:
The facility is a white stucco structure with white trim one-story house with a garage with 6 bedrooms, 2 bathrooms/bedroom, 1 living room, and a restaurant style open kitchen. The client bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 1 exit ways on each side of the house with shaded seating area for residents.

Signal system:
Central air/heating system installed with a central panel to control entire house.

Bedrooms Residents:
Bedrooms are for 5 non-ambulatory and 1 bedridden. One bedroom will accommodate 2 residents being a shared room.

Bedrooms Staff:
1 bedroom will be for live in staff.

CONTINUED on LIC809-C
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STERLING SENIOR COMMUNITY VI
FACILITY NUMBER: 306006007
VISIT DATE: 06/24/2021
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Bathrooms:
All bathrooms have a working toilet, wash basin, bath-tub/shower.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway cabinet space.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are to be stored in the kitchen. There is an extra refrigerator in garage with food supply.

Smoke Detectors:
Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational.

Appliances:
Gas four-burner stove, single oven, 2 refrigerator/freezer (kitchen and garage), dish washer, microwave, washer, and dryer are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients are stored and locked in a storage cabinet located garage.

Water Temperature:
Tested and recorded the water temperature measures 108.3 Fahrenheit degrees in all restrooms.

CONTINUED ON LIC809-C
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STERLING SENIOR COMMUNITY VI
FACILITY NUMBER: 306006007
VISIT DATE: 06/24/2021
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Medications, First-Aid Kit & Book:
Medication stored in storage cabinet with lock inaccessible to residents. Facility has 3 First aid kits is stored with medication and storage cabinet.

Clients & Staff Files:
Records will be kept locked with medication cabinet.

Pool/Jacuzzi & Pets:
No bodies of water in facility.

Fire Extinguisher:
Mounted in wall dated October 07, 2020.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the residents use, commensurate with the plan of operation.

Fire clearance:
Was approved on 11/23/2020.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

All items reviewed during the visit are in compliance. Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor.
Exit interview was conducted and a copy of this report was left with the applicant.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
LIC809 (FAS) - (06/04)
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