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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006007
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:32:55 PM

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-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:
03/07/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Daisy Justo-Caregiver, Kian Pascual-StaffTIME COMPLETED:
03:47 PM
ALLEGATION(S):
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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:
1
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3
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5
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10
11
12
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 Daisy Justo. 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: One of five individuals interviewed confirmed the allegation. During the investigation LPA reviewed documents including the Medication Administration Record (MAR) dated December 2023 for Resident 1 (R1) and R2. Per MAR staff are properly administering R1's and R2's medications. During the course of the interviews with residents R1 reported that staff manage their medications properly and stated that staff are attentive.
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
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: 03/07/2024
NARRATIVE
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Regarding the allegation that facility failed to maintain a complete and accurate resident’s records, the investigation revealed the following: During the investigation LPA reviewed documents including the Sterling Senior Community 6 Register of Facility Residents (LIC9020A). LPA observed that the Register of Facility Residents was completed in all required sections which include Room Identifier, Resident Name and Language, Ambulatory Status, Physician contact information and Representative contact information. LPA reviewed documents including the Resident Appraisal for R3 and R4. LPA observed that all sections of Resident Appraisal for R3 and R4 were completed, dated and signed.

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 04/04/23 and for S2 dated 04/07/23. LPA observed that all sections on the Health Screening Report - Facility Personnel for S1 and S2 were completed, dated and signed. LPA also reviewed S1 and S2 files and observed that the files included the Personnel Report (LIC501), results for negative Tuberculosis test, Criminal Record Statement and Out -Of-State Disclosure, Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders, and Notice of Employee Rights.

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: 2 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.
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:
03/07/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Daisy Justo-Caregiver, Kian Pascual-StaffTIME COMPLETED:
03:47 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 Daisy Justo. 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: One of five individuals interviewed confirmed the allegation. During the investigation LPA reviewed documents including the Sterling Senior Community 6 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 four residents in care. During the course of the interviews with residents, Resident 1 (R1) reported that the facility has enough staff and stated that staff are attentive and respond quickly. Per R1 this is the place to be if you need assistance.
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: 3 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: 03/07/2024
NARRATIVE
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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: 4 of 4