Sterling Senior Community I

Type of visit: Office

Licensing Program Managers (LPM) Kevin Saborit-Guasch and Alisa Ortiz along with Licensing Program Analyst(LPA) Nancy Guillen met with Licensee Albert Pimentel and Michelle Kellogg in regards to concerns with consistency of complaints investigations and also wanted clarification on Title 22. The following were discussed: - Complaint Investigation Process - Expectations of collaboration between LPAs and Licensees - Appeal rights - Title 22 requirements regarding staff training, awake staff, and staff records Licensee expressed intention to continue building rapport with the department An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 21, 2026

Allegation investigated: Resident sustained injury while in care.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit upon entering the facility. At the beginning of the visit, LPA was led on a tour of the facility by staff. Observations were made and photos were taken. Regarding the complaint allegation above, interviews were conducted with staff, resident, a witness, and documents were reviewed. Attempts were made to interview other individuals who could possibly provide details on the complaint allegation, and calls/emails were not returned and/or contact information LPA received was no longer working. Resident 1 (R1) could not be interviewed, as R1 passed away after the incident. A death certificate for R1 was provided. R1’s death was not related to the injury suffered while in care. During the investigation, 4 of 4 individuals including staff were unable to recall any corroborating information about the incident that occurred on July 21, 2021, involving R1. Continued on LIC9099C Unsubstantiated Two staff members who were interviewed did not recall specific details of the incident; however, both staff members did remember the resident and vaguely remembered the incident that occurred on July 21, 2021. The resident who were here at that time did not have any information to provide regarding R1 or the incident. Document review revealed the following: Per SOC341 dated July 23, 2021 – Per EMS, patient was found on the floor for an unknown amount of time due to unwitnessed fall. Patient has forehead laceration due to fall. Per incident report provided by the facility, dated July 22, 2021 – Around 1:00am a caregiver found R1 sitting on the floor. The facility staff member called hospice and a staff from Compassionate Care Hospice told facility staff to call 911. 911 was called and the resident was sent to Hoag Memorial Hospital in New Port Beach. Although R1 did fall and suffer an injury, it is unclear if the fall and injury is related to neglect of R1’s care needs. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 22-AS-20210723134206

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit regarding observations made during the investigation into complaint control # 22-AS-20210723134206. During the complaint investigation mentioned above, LPA Haley made several observations on a complaint visit conducted August 14, 2024, to gather information on the recently reassigned complaint. During the visit, there was a woman in the kitchen who refused to provide her name. The woman said she was just there to wash the dishes and eventually left through the garage. When the Administrator arrived the name of individual was provided. During a subsequent visit, the same staff member confirmed the woman who was observed in the kitchen during the August 14, 2024, visit was sent to get fingerprinted after the visit on August 14, 2024. A review of guardian shows the individual observed in the kitchen was associated September 22, 2024, after the August 14, 2024, visit was conducted. During the same visit, when LPA toured the facility the stove, dishwasher, and a table in the backyard were observed in disrepair. Photos were taken. The next day, on August 15, 2024, LPA Haley received an email with a video of a repaired stove that ignites without assistance and a new table with chairs in the backyard. IN the same email LPA was informed a new dishwasher was purchased and once installed, photos would be provided. As a result of today’s Case Management visit, deficiencies will be cited for the observations that were made July 19, 2024. Several photos were taken, and staff confirmed all the deficiencies that were observed including the unassociated individual present in the facility upon LPA’s arrival. An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 10, 2025

87355 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by: One uncleared and unassociated individual was present in the facility upon LPA's arrival August 15, 2024 which poses a threat to the health and safety of the residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2025

Plan of correction: The individual was fingerprinted and has been associated to the personnel roster since September 22, 2024. No further corrections needed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 10, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: During a visit to the facility on July 19, 2024, LPA observed the stove, dishwasher, and a table in the backyard in disrepair.the state’s words, verbatim · CDSS document, Oct 10, 2025

Plan of correction: On August 15, 2024 the Administrative representative emailed LPA Haley a video of a repaired stove, and a new table in the backyard. Further, upon arrival during today's visit, LPA Haley observed a new dishwasher was purchased and installed. No further corrections needed.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrators Kian Pascual and Sheryl Tongol and discussed the purpose of the visit. The facility currently has six residents in care. The facility is a one story home with seven bedrooms, three bathrooms, living room, dining area, kitchen, backyard, and attached two car garage. LPA observed 1 of 3 staff to not be background cleared and associated to the facility. An immediate civil penalty was assessed. LPA observed the resident bedrooms to have the required components and furnishings. LPA observed the bathrooms to have toilet paper, paper towels, and textured flooring in the shower. LPA tested the water in the bathrooms to be between 119.4-119.8 degrees Fahrenheit. LPA observed the centrally stored medication to be in a locked cabinet located in the living room. LPA observed the kitchen to be clean and free of vermin. LPA observed the knives to be in a locked drawer located by the refrigerator. LPA observed a two day perishable and seven day nonperishable food supply on hand. LPA observed the toxins and chemicals to be in a locked cabinet located in the locked garage. LPA observed the emergency food and water supply to be stored in the garage. LPA observed fire extinguishers in the dining room and garage charged and with a service date of December 3, 2024. LPA observed the backyard to have a shaded seating area for resident use. LPA observed pathways are free of obstructions. LPA reviewed staff files and 1 of 2 staff do not have updated annual training. LPA observed resident files and 1 of 6 residents do not have a medical assessment on file, 5 of 6 residents do not have bed rail orders, and 5 of 6 residents do not have updated or signed needs and services plans. LPA observed resident medications and no discrepancies were observed. LPA observed the last fire drill to be conducted on July 5, 2025. Continue on LIC 809-C Based on today’s observations citations, a civil penalty and technical violation are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility representatives Tongol and Pascual and a copy of this report along with LIC 809-D, LIC 858, LIC859, appeal rights, technical violation, and LIC421BG were given at the time of inspection.the state’s words, verbatim · CDSS document, Sep 3, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by caregiver. Kian Pascual arrived at the facility and met with LPA. There are four residents at the facility and there are no residents receiving hospice services currently. LPA accompanied by caregiver began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. The facility stays within the capacity limitations. There is a minimum of one week of non-perishables located in garage pantry. There is two perishables food available and there is additional food storage in a freezer and in an additional refrigerator located in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the living room. LPA reviewed medication and cross checked with medication logs. Medication was observed to be labeled and stored inaccessible to residents in care. LPA inspected the facility bathrooms and LPA measure the hot water temperature which measured 113.5 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathroom are equipped with required safety measures such as non-skid mats and grab bars. Lighting I sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solution and disinfectant are store locked in a storage cabinet locate in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedroom which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways to be free of obstruction. LPA observed there are shaded seating areas for residents’ enjoyment. LPA observed a fire extinguisher mounted on the wall of the dining room with a service date of December 3, 2024. LPA reviewed Continued on LIC809-C fire drill logs and verified drills are conducted quarterly with last fire drill conducted January 1, 2025. LPA began review of records; LPA reviewed four resident records. All the required documentation was present and current in the residents’ file review. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed a current Administrator Certificate mounted on the wall on the facility. LPA observed a current first aid certificate on file for employee. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 5, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management regarding observations made during a complaint visit. While investigating complaint control number 22-AS-20210723134206, LPA Haley observed an unidentified woman in the facility who refused to identify herself. Once the resident refused to identify herself and provide identification, she was asked to leave the facility. While touring the facility additional observations were made, LPA Haley observed a pile of debris on the side of the facility including walkers, old blinds, an old wheelchair, and other items. In the kitchen the top right burner on the gas stove would not light, and the dishwasher is not in working condition. Photos were taken of the dishwasher and the pile of debris on the side of the facility. As a result of today’s case management visit, deficiencies will be cited. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 14, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d) · Plan of correction due date: Aug 15, 2024

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement is not met as evidenced by: An unidentified woman was answered the door upon LPA's arrival and refused to provide her name and identification when asked. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Administrator agrees to read and review regulation section 87355 Criminal Record Clearance and send a signed statement of acknowledgement and understanding. Administrator Pascual and Licensee Pimenentel agree the unidentified woman is not allowed to come back inside the facility until she is fingerprint cleared and associated to the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Aug 21, 2024

Maintenance and Operation (87303)(a)(1): (a) The facility shall be clean, safe, sanitary and in good repair at all times... for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: LPA Haley observed a pile of debris on the side of the facility that needs to be removed. The dishwasher in the kitchen needs to be replaced or repaired and the top left burner on the gas stove needs to be repaired or replaced. Photos were taken of the dishwasher, and the pile of debris on the side of the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Licensee Pimenentel and Administrator Pascual agree to have the stove repaired or replaced, the dishwasher will be replaced, and the pile of debris will be removed from the side of the home by the poc due date. Photos of the side of the facility will be emailed by the POC Due date. A receipt was provided for a new dishwasher and a photo will be emailed to LPA once it arrives. A video of the stove lighting unassisted or a receipt will be provided if a new stove is purchased.

Allegation investigated: Facility is in disrepair. Facility staff failed to properly administer resident’s medications. Facility failed to maintain a complete and accurate staff records. Facility failed to maintain a complete and accurate resident’s records.

This is an amended copy of the report previously issued on 12/13/2023. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same. On 12/13/23, at 9:05am, Licensing Program Analyst (LPA) Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by caregiver Ireland Torren (S1). The administrator was called and arrived at 10:25am. LPA asked for the census, staff, and resident files. Regarding the allegation: Facility failed to maintain a complete and accurate resident’s records. It is being alleged that the resident records were not complete and accurate. LPA observed two staff present. LPA asked how many staff are currently working and the staff stated two staff are presently working. The resident files were reviewed for all five (5) residents. All five (5) residents had the identification/emergency-601, admission agreement, physician report, telecommunications, medical consent, 9099-C-continued Unsubstantiated This is an amended copy of the report previously issued on 12/13/2023. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same. preplacement/resident appraisal, Appraisal needs and services plan, personal rights of the residents, physician progress reports, consent forms. LPA did not observe the resident records to be incomplete and inaccurate. The LPA attempted to interview five (5) out of five (5) residents, but due to their inability to communicate with words, that could not be completed. Regarding the allegation: Facility failed to maintain a complete and accurate staff records. It is being alleged that the staff records were not complete and accurate.LPA reviewed all personnel record, health screening with TB test results, CPR/first aid, employee rights, statement acknowledging requirement to report suspected abuse of dependent adults and elders, criminal background and in service/training. All records were observed, reviewed and copies were obtained. The LPA did not observe the staff records to be incomplete and/or inaccurate. The LPA was able to interview four (4) staff. Regarding the allegation: Facility is in disrepair. It’s being alleged that the physical plant is in disrepair.LPA conducted a physical plant tour of the facility at 9:45a.m. There is a total of seven (7) bedrooms. Six (6) bedrooms is used for residents (single occupancy). The resident's room was equipped with proper bedding and lighting. There is a total of three (3) bathrooms. There is also smoke detectors and carbon monoxide detectors throughout the house in working order. There is a backyard that has a shaded area and seating for all residents. During interview with staff, staff did not report any disrepair with the facility. LPA did not observe the physical plant to be in disrepair. Regarding the allegation: Facility staff failed to properly administer resident’s medications. LPA reviewed all five (5) resident medications and Medication Administration Records (MAR). Records were reviewed and were observed to be properly distributed according to the medication record. The LPA observed the bubble packs to have the accurate date and were properly dispensed. The AM, PM and bedtime were administered up to/leading to 12/13/23. There was also PRN- (as needed medication) in bubble packs. The medication was labeled per resident name in separate binders, stored and locked in a cabinet inaccessible to the residents. LPA did not observe the resident medication to not be properly administered. Based on the LPA's interviews, observations, and record reviews all four allegations above are unsubstantiated at this time. All copies of records/files were obtained. An exit interview was conducted, no citations were issued for the four (4) above allegations, and a copy of this report was given to the administrator. This is an amended copy of the report previously issued on 12/13/2023. After review of this complaint, it was determined corrections to the verbiage was warranted. The complaint findings remain the same. LPA spoke to the Licensee to verify how many staff are working on the weekend and overnight. Licensee stated, ‘there is no staff that work overnight. They have live-in staff in case anything goes wrong.” LPA conducted a record review which indicated resident with dementia are currently in care at the facility. Based on LPAs observations, interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter 6), are being cited on the attached LIC-9099D.”) when there is care of residents with dementia Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty. There are currently three (3) residents out of five (5) residing at the facility with a current diagnosis of dementia. An exit interview was conducted, citation given, appeal rights, and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Dec 13, 2023 · control 22-AS-20231211122154

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4)(A) · Plan of correction due date: Dec 13, 2023

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia...(4)There is an adequate number of direct care...safety and health care needs… (A) In addition to... specified in Section 87415, Night Supervision, a facility with fewer than 16...at least one night staff person...This requirement is not met as evidenced by: Based on the observation, interviews and record reviews, the licensee did not ensure one out of five staff at the facility to be on duty at night and supervise the care of the residents of dementia have which poses immediate Health, Safety or Personal Rights risks to person in care.the state’s words, verbatim · CDSS document, Dec 13, 2023

Plan of correction: The licensee/admnistrator will send the LPA an updated personnel report showing the caregivers schedule showing there is a night person on duty seven (7) days out of the week to care for residents with dementia. POC 12/14/23