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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006007
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:18:56 PM

Substantiated


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-20231211124014
FACILITY NAME:STERLING SENIOR COMMUNITY VIFACILITY NUMBER:
306006007
ADMINISTRATOR:KELLOGG, MICHELLEFACILITY TYPE:
740
ADDRESS:140 N WHEELER STTELEPHONE:
(714) 538-9615
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 4DATE:
12/14/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Daisy Justo-Caregiver, Kian Pascual-StaffTIME COMPLETED:
04:34 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegation and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Caregiver Daisy Justo. LPA explained the reason for the visit.

On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: One of five individuals interviewed corroborated the allegation. During the initial visit on 12/14/23 LPA toured the facility, LPA observed and took pictures of a chair in the dining room, the kitchen floor tile, the kitchen pantry and hallway restroom door and baseboard. In the dining room LPA observed that the chair cover was ripped exposing the chair inner cushion. At 1:34 PM LPA observed that the kitchen's pantry paint is chipped and has black discoloration. At 1:36 PM LPA observed that the kitchen floor tile below the knives' cabinet is broken and has brown and black discoloration.
CONTINUED ON LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
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
Control Number 22-AS-20231211124014
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 VI
FACILITY NUMBER: 306006007
VISIT DATE: 12/14/2023
NARRATIVE
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In the hallway restroom LPA observed that the entrance door and baseboard next to the shower have chipped paint, black discoloration and/or are scraped. At 2:28 PM LPA observed that the base of the railing leading to the back yard has chipped paint, is scraped and rusted.

Based on LPA's observation and information gathered during the investigation, the preponderance of evidence standard has been met, therefore the following allegation: facility is in disrepair is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with staff Pascual and a copy of this report and the Appeal Rights were provided at the time of this visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20231211124014
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 VI
FACILITY NUMBER: 306006007
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by:
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Licensee to provide pictures of repaired kitchen tile, pantry, yard railing, hallway restroom and baseboard and dining room chair by POC due date.
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During the 10-Day complaint visit LPA observed that the kitchen tile, pantry, yard railing and hallway restroom and door have chipped paint, are scraped, have black discoloration and/or are rusted. LPA also observed a dining room chair with a ripped cover exposing the chair inner cushion.
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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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4