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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006007
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:51:55 PM

Document Has Been Signed on 08/23/2024 03:51 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 VIFACILITY NUMBER:
306006007
ADMINISTRATOR/
DIRECTOR:		KELLOGG, MICHELLEFACILITY TYPE:
740
ADDRESS:140 N WHEELER STTELEPHONE:
(714) 538-9615
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY: 6CENSUS: 4DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Daisy Justo-Caregiver, Kian Pascual-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:07 PM
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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 Daisy Justo. Administrator (AD) Kian Pascual arrived shortly after.

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

LPA observed the Administrator's Certificate for Kian Pascual which expired on 05/24/24, however, AD provided proof of payment to show that the certificate is in renewal process. Renewed certificate has not yet been received and is pending. LPA reminded Licensee to post certificate once received.

LPA Ramirez toured the interior and exterior portions of the facility with caregiver Justo. The facility is a single level structure and is licensed for six non-ambulatory residents, of which four may be on hospice and one bedridden. There are a total of six bedrooms, of which five are resident bedrooms, and one 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 two 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 110.6-114.6 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. Fire extinguishers were charged and one was located by the dining room/living room, two in the kitchen, one by the main entrance and one in the garage.

CONTINUED ON LIC809-C..

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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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 VI
FACILITY NUMBER: 306006007
VISIT DATE: 08/23/2024
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AD to print and post the emergency disaster and evacuation plan. Facility had back-up emergency food and water supply. 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 area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard. No bodies of water were observed.

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

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Pascual.

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: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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