306006201-9-22-2022-22-AS-RQUZ-CJHNXF-20220922105105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006201
Report Date: 09/22/2022
Date Signed: 09/22/2022 10:51:46 AM

Document Has Been Signed on 09/22/2022 10:51 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 9		FACILITY NUMBER:	306006201
ADMINISTRATOR:	LALAP, DONNAVEE		FACILITY TYPE:	740
ADDRESS:	10448 NIGHTINGALE CIRCLE		TELEPHONE:	(714) 213-3045
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY: 6		CENSUS: 6	DATE:	09/22/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Michelle Kellogg, Licensee, Donnavee Lalap, Administrator and Kian Pascual, Administrative Assistant.		TIME COMPLETED:	11:05 AM

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an announced visit to the facility for purpose of a Change of Ownership Pre-Licensing evaluation inspection visit. LPA Quiroz was greeted and granted entry and met with Michelle Kellogg, Licensee, Donnavee Lalap, Administrator and Kian Pascual, Administrative Assistant.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to the Central Applications Unit (CAU) on 6/20/2022 for a capacity of six (6) residents, five (5) Non-Ambulatory residents and (1) one bedridden resident.

Administrator Donnavee Lalap has an Administrator Certificate with expiration date of 3/10/2024.

LPA Quiroz provided consultation on Title 22 California Code of Regulations (CCR) and on new Inspection Tool.

At approximately 9:27am, LPA Quiroz along with Administrator Lalap commenced the inspection tour.

During today's inspection visit, LPA Quiroz observed the following:

Structure:Facility is a one story building, consisting of: 6 private resident bedrooms, (1) one caregiver bedroom, (2) two full bathrooms, and (2) two half bathrooms. Bedroom #5 is designated as bedridden resident bedroom only. The resident bedrooms will accommodate residents' furnishings. There is one living room, kitchen, dining room area, Common Family Room, 2 car garage with operational washer and dryer, and back yard with shaded area and outdoor furniture for residents and visitors enjoyment.

Toxins: Will be locked and stored in secured closet in garage area, not accessible to residents in care.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STERLING SENIOR COMMUNITY 9	FACILITY NUMBER: 306006201
	VISIT DATE: 09/22/2022

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Water Temperature: Water temperatures were tested and recorded to be between 105.2- 105.8 degrees F.

Linens and Hygiene Supplies: Facility will have available linens upon residents move in, and extra linen and hygiene supplies available for residents in care, and stored in linen closet in main hallway.

Medications, First Aid Kit & Manual: Medication will be stored secured and locked in medication closet near kitchen area. First Aid Kit and Manual will be stored in medication closet readily available for staff and residents in care.

Resident and Staff Files: Records will be kept in a locked and secured area in kitchen area.

Signal System: Facility has internal heating and air conditioner. The temperature inside the facility was recorded to be 76 degrees F.

Bedrooms Residents: Bedrooms will accommodate residents.

Bathrooms: All bathrooms have a working toilet, wash basin, and walk-in shower.

Emergency Phone Numbers, Exit Plan, and Sample Menu: Readily available and posted in dining area.

Food Service: Adequate supply of 7-day non-perishable and 2 day perishables would be stored in the kitchen, pantry and in garage area. LPA Quiroz observed second refrigerator for extra food storage in garage area.

Fire Extinguisher: LPA Quiroz observed 6 fire extinguishers in facility, Last serviced on 6/15/2022.

PPE: LPA Quiroz observed supply of PPE in garage area readily available for staff and residents in care.

Fire Clearance: Approved on 8/10/2022. LIC 610 E form observed posted near entrance area readily available for staff and residents in an event of an emergency.

Appliances: Appliances were observed operational and in good repair.

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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: STERLING SENIOR COMMUNITY 9	FACILITY NUMBER: 306006201
	VISIT DATE: 09/22/2022

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Component III: Component III was completed today with Administrator Donnavee Lalap, Licensee Michelle Kellogg and Administrative Assistant Kian Pascual.

On 8/10/2022, the fire clearance was granted for a capacity of 6 residents, (5) five non-ambulatory residents and one (1) bedridden. Bedridden resident in Bedroom #5 only.

Facility is ready for licensure and final approval will be processed by the Central Applications Unit.

Administrator Donnavee Lalap was reminded of the statute that requires facility to notify Rosie Quiroz, Licensing Program Analyst at (559) 753-4610 within 5 business days of admitting the first resident new resident. This notification may be done by phone, mail, email or fax. LPA Rosie Quiroz provided Applicant with business card to facilitate communication with LPA Quiroz.

An exit interview was conducted with Administrator Donnavee Lalap and Administrative Assistant Kian Pascual and a copy of this report was provided via email due to technical difficulties.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

LIC809 (FAS) - (06/04)

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