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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006219
Report Date: 04/28/2026
Date Signed: 04/28/2026 04:12:34 PM

Substantiated


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 Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20231211124212
FACILITY NAME:STERLING SENIOR COMMUNITY 7FACILITY NUMBER:
306006219
ADMINISTRATOR:LALAP, DONNAVEE C.FACILITY TYPE:
740
ADDRESS:9231 EL CORTEZ AVETELEPHONE:
(714) 847-1364
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Kian PascualTIME COMPLETED:
04:11 PM
ALLEGATION(S):
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Facility staff failed to properly administer resident’s medications.
Facility failed to maintain a complete and accurate resident’s records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged facility staff failed to properly administer resident's medications and facility failed to maintain a complete and accurate resident’s records. LPA conducted interviews with staff and residents. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation facility staff failed to properly administer resident's medications, it was reported medications are not administered per Title 22 regulations. Interviews with one out of five residents stated they are assisted with medications. The one resident stated they receive medications after meals. The remaining five residents could not be qualified for interviews. Two out of three staff stated Staff 1(S1) assist residents with medication administration. The remaining staff stated S1 and Staff 2 (S2) assist with medication administration.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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 7
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 Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20231211124212

FACILITY NAME:STERLING SENIOR COMMUNITY 7FACILITY NUMBER:
306006219
ADMINISTRATOR:LALAP, DONNAVEE C.FACILITY TYPE:
740
ADDRESS:9231 EL CORTEZ AVETELEPHONE:
(714) 847-1364
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Kian PascualTIME COMPLETED:
04:11 PM
ALLEGATION(S):
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2
3
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5
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7
8
9
Facility is in disrepair.
Facility is not adequately staffed.
INVESTIGATION FINDINGS:
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5
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7
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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged facility is in disrepair and facility is not adequately staffed. LPA conducted interviews with staff and residents. LPA reviewed records obtain.

The investigation determined as follows: Regarding the allegation facility is in disrepair, LPA toured the facility with staff to determine if the facility is clean, safe, sanitary and in good repair. During the tour, LPA did not observe any physical plant issues. Resident rooms had the appropriate furnishings, smoke and exit alarms were operational, and water temperatured measured between 106.5 and 110.3 degrees F in all resident bathrooms checked.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20231211124212
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 7
FACILITY NUMBER: 306006219
VISIT DATE: 04/28/2026
NARRATIVE
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 Interviews with one out of five residents stated the facility has remained in good repair overall. The remaining four residents could not be qualified for interviews. Interviews with three out of three staff stated there are maintenance persons who are available to make repairs to the facility as needed.

Regarding the allegation facility is not adequately staffed, it was reported there is insufficient staff to meet the needs of the residents. LPA interviews with one out of five residents stated their needs are being met by staff and there has not been an issue with staffing. The four remaining residents could not be qualified for interviews. Three out of three staff stated there is sufficient staff coverage and several back up staff is available when needed. LPA record review of the LIC500 indicates there are seven caregivers available or on call with at least two caregivers scheduled to work from 7AM to 8PM and one caregiver scheduled to work from 8PM to 8AM. LPA reviewed schedule indicating two staff during the day shift and one staff during the night shift from March to May 2026.

Based on interviews and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of the report was left with the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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 Fred Arias
COMPLAINT CONTROL NUMBER: 22-AS-20231211124212

FACILITY NAME:STERLING SENIOR COMMUNITY 7FACILITY NUMBER:
306006219
ADMINISTRATOR:LALAP, DONNAVEE C.FACILITY TYPE:
740
ADDRESS:9231 EL CORTEZ AVETELEPHONE:
(714) 847-1364
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 5DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Kian PascualTIME COMPLETED:
04:11 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to maintain a complete and accurate staff records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged facility failed to maintain a complete and accurate staff records. LPA conducted interviews with staff. LPA reviewed records obtained.

Regarding the allegation facility failed to maintain a complete and accurate staff records, it was reported staff records were not compliant with Title 22 regulations. LPA reviewed four staff records. Four out of four staff records included but not limited to evidence of health screening, training, background clearance, TB testing, and job applications.Two out of four staff files did not include evidence of verified CRP/First Aid training. Interviews with two out of three staff stated they have received training within the last year. The two staff stated they completed training online with a third party vendor. The remaining staff could not recall when the last training was completed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20231211124212
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 7
FACILITY NUMBER: 306006219
VISIT DATE: 04/28/2026
NARRATIVE
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Based on interviews and records observed, the allegation is therefore deemed unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of the report was left with the facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20231211124212
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 7
FACILITY NUMBER: 306006219
VISIT DATE: 04/28/2026
NARRATIVE
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S1 added there has never been an instance where medications were not available or delayed.

During the initial complaint visit conducted by the Department on December 14, 2023, it was observed Miralax was available at the facility. When the Department questioned who the Miralax belong to, staff stated it belonged to Resident 7 (R7). The Department did not observe Miralax in R7's medication administration record. The staff removed the Miralax from the facility and stated they would obtain a physician's order to provide to R7. Record review revealed R7 moved out of the facility on October 14, 2024. LPA reviewed R7's medication administration record for the months of September, October, and November 2023. LPA also reviewed medication list from hospice for R7 dated October 7, 2023. Neither indicates Miralax or Polyethylene Glycol Powder as part of R7's medications.

Regarding the allegation facility failed to maintain a complete and accurate resident’s records, it was reported resident records and not maintained per Title 22 regulations. The centrally stored medication and destruction record for R7 was not available to review. Administrator (AD) Kian Pascual stated those records were lost when the facility transitioned into their current record keeping system.

Based on interviews conducted, records reviewed, and observations, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be SUBSTANTIATED.

California Code of Regulations, (Title 22, Division 6), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of the report was left with the facility representative along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20231211124212
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 7
FACILITY NUMBER: 306006219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2026
Section Cited
CCR
87465(h)(6)(C)
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87465(h)(6)(C)Incidental Medical and Dental Care
The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident...and includes: The drug name, strength and quantity
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AD stated medication documentation in-service training will be conducted staff. AD to provide proof of training to LPA by POC date.
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This requirement is not met as evidenced by:

Miralax for R7 was observed at the facility. No Centrally stored and medication list was available for R7 to review which poses a potential health and safety risk to persons in care.
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Type B
05/15/2026
Section Cited
CCR
87506(e)
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87506(e) Resident Records

Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.
This requirement is not met as evidenced by:
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AD stated records for resident will be backed up by USB and retained for at least three years after the resident discharges. AD to submit a statement of acknowledgement of the regulation and inform LPA when backup is completed.
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R7's centrally stored medication and destruction record is no longer available. R7 discharged from the facility on 10/14/2024 which poses a potential health and safety risk to persons in care.
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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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7