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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006201
Report Date: 10/03/2025
Date Signed: 10/03/2025 05:43:05 PM

Document Has Been Signed on 10/03/2025 05:43 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 9FACILITY NUMBER:
306006201
ADMINISTRATOR/
DIRECTOR:		SAMUEL MANALOFACILITY TYPE:
740
ADDRESS:10448 NIGHTINGALE CIRCLETELEPHONE:
(714) 594-3568
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
10/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator - Sheryl TongolTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On October 3, 2025, at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted and granted entry by Caregiver (CG) Olimpia Lang, after stating the purpose of the visit. Administrator (AD) Sheryl Tongol arrived at the facility at short time later and was present throughout the inspection.

The facility is licensed to operate for six (6) non-ambulatory residents, of which one (1) may be bedridden, and has a hospice waiver for four (4) residents. The building is a single story structure located in a residential neighborhood. It consists of the following: six (6) resident bedrooms, one (1) staff bedroom, four (4) bathrooms, living room area, dining area, kitchen, an outdoor covered seating areas, and an attached two car garage.

During the inspection, LPA obtained copies facility records including: Resident/Staff Roster, LIC 500 (Personnel Record), Staff Schedules for September and October 2025, and proof of Liability Insurance. Based on record review and interviews, S1 and S2 was not associated prior to working at the facility which poses an immediate Health, Safety, or Personal Rights risk to persons in care. Civil Penalties Assessed.

LPA Bentley toured inside and outside of the physical plant with AD Tongol. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked and available at the time of visit. Bathrooms were found to be clean and operational. The water temperatures in four (4) bathrooms measured between 122.5 – 132.9 degrees F. A deficiency is being cited.

Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 10/03/2025 05:43 PM - It Cannot Be Edited


Created By: Eboni Bentley On 10/03/2025 at 02:54 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 9
FACILITY NUMBER: 306006201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87608(a)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


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 9
FACILITY NUMBER: 306006201
VISIT DATE: 10/03/2025
NARRATIVE
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A comfortable temperature of 76 degrees F was maintained in the facility. LPA Bentley observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency safety drills were last conducted on July 11, 2025, and conducted quarterly. First aid kit is maintained and contains all the necessary elements.

During the visit, the smoke detectors and carbon monoxide detectors were tested and operable. A working telephone (714-594-3568) remains available, and the facility has a device that can be used for video teleconference purposes. Emergency food, emergency water, and emergency supplies were stored in the garage. The facility has two (2) fire extinguishers that were charged, mounted, and last serviced on July 11, 2025. Liability Insurance is effective November 18, 2024, and expires on November 18, 2025.

LPA Bentley conducted an audit of six (6) resident files (R1-R6), five (5) staff files (S1-S5), and medication and medication administration review were conducted. A review of six medication administration records revealed inconsistencies, and a deficiency is being cited. During the visit, LPA Bentley conducted resident interviews and staff interviews regarding care provided.

Based on observations, deficiencies and civil penalties are being cited during this visit as per Title 22 Division 6 of the California Code of Regulations.


An exit interview was conducted, and a copy of this report, LIC809-D, LIC811s, LIC421BG, and appeal rights were provided to Administrator Sheryl Tongol at the end of the visit.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Eboni Bentley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2025 05:43 PM - It Cannot Be Edited


Created By: Eboni Bentley On 10/03/2025 at 05:01 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 9
FACILITY NUMBER: 306006201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in two out of five staff records, which poses a potential risk to residents in care. S1 and S2 were not associated to the facility at the time of the inspection. Two Civil Penalties are Assessed.
POC Due Date: 10/04/2025
Plan of Correction
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Licensee associated S1 and S2 during visit and LPA observed records to confirm.
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not compy with the section cited above in three out of three resident bathrooms where hot water temperatures measured between 122.5 and 132.9 degrees F. This poses an immediate risk to persons in care.
POC Due Date: 10/04/2025
Plan of Correction
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Licensee adjusted water temperatures in all bathrooms during visit and LPA tested measurments to confirm.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2025 05:43 PM - It Cannot Be Edited


Created By: Eboni Bentley On 10/03/2025 at 05:01 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 9
FACILITY NUMBER: 306006201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's ..... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for 3 of 6 residents, poses a potential health, safety and personal rights risk to persons in care. LPA observed R1 had 1/2 bed rails installed on bed without Physicians order, R2 had a Physican's order for a 1/2 rail and did not have bedrails installed. Record review and interview revealed licensee did not have a written order from a physician in residents' files. LPA observed R3 had a full bed rail installed on bed, and record review revealed there is a physician's order for a 1/2 rail and R3 is not on hospice. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
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Licensee to remove the bed rails for R1 and obtain physician orders for 1/2 bedrails, install 1/2 bedrail for R2 per Physician's order, and submit proof to CCL by 10/10/2025. During visit, licensee removed full bedrail for R3 and installed 1/2 rail on bed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Eboni Bentley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
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