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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006151
Report Date: 11/20/2024
Date Signed: 11/20/2024 05:30:40 PM

Document Has Been Signed on 11/20/2024 05:30 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 8FACILITY NUMBER:
306006151
ADMINISTRATOR/
DIRECTOR:		PIMENTEL, ALBERTFACILITY TYPE:
740
ADDRESS:15442 COLUMBIA LANETELEPHONE:
(714) 357-1377
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 4DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:19 AM
MET WITH:Assistant Administrator, Kian PascualTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
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On November 20, 2024 at 9:19 am, Licensing Program Analyst's (LPAs) Jenifer Tirre and Eboni Bentley conducted an unannounced required visit using the CARE Inspection Tool. LPAs were greeted by staff and granted entry after stating the purpose of the visit. Administrator (Admin) Albert P. Nanez was not present. Administrator (Admin) Kian Pascual was present to assist with the facility inspection on today's date.
 
The facility is licensed for six (6) non-ambulatory residents, one (1) bedridden, with approved hospice waiver for six (6) residents. Currently, there are four (4) residents of which there are two (2) hospice residents and (1) bedridden resident present during today’s visit.

This is a single story with attached garage facility. The facility has six private bedrooms and three full bathrooms, currently occupied by four residents.
At around 9:30am, LPAs conducted a tour of the physical plant accompanied by Admin Pascual, and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were in operational condition, lighting was provided in all rooms, and storage for the client's personal belongings were observed in residents’ closets. Additional bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperatures measured between 114.4 to 116.9 degrees F. maintained in the bathrooms within the facility.

LPAs observed the facility to be furnished at the time of the visit. Storage areas for toxins and sharps objects were stored and not accessible to residents. The kitchen was inspected, appliances such as stove, oven and fridge were operational. Sufficient perishable and non-perishable food was maintained adequately. Facility has emergency food and water supply. Facility has two fire extinguishers which are mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPAs observed the records are in compliance. 
 
During the visit, LPAs observed the facility's infection control practices. LPAS observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPAS observed the facility has a  supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.
CONTINUED ON LIC 809
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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 8
FACILITY NUMBER: 306006151
VISIT DATE: 11/20/2024
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LPA's observed First Aid Kit was maintained. The last fire drill was conducted on September 19, 2024. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas.
 
A review of four residents (R1-R4) service files and four staff (S1-S4) personnel files revealed to be complete. The facility has the current administrator's certification on file for Albert P. Nanez with Expiration Date: 04/18//2025. Facility has liability insurance on file effective 11/18/24-11/18/25.
 
The current items were addressed during visit:
  • Facility plumbing is exposed and capped leading to hallway. Licensee to cover area and have plumbing redirected
  • facility thresholds between kitchen and hallways and laundry doors need to be shaved down.

The following will be cited on 9099 D page
 
An exit interview was conducted with Administrator Kian Pascual, and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 05:30 PM - It Cannot Be Edited


Created By: Jenifer Tirre On 11/20/2024 at 04:58 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STERLING SENIOR COMMUNITY 8
FACILITY NUMBER: 306006151

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation(interview), the licensee did not comply with the section cited above in facility has plumbing that is exposed in hallway and facility threshold between kitchen area hallways and laundry exit needs to be shaved down to avoid tripping hazared which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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Licensee to repair exposed plumbing and facility thresholds by POC due date 12/4/2024
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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