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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803555
Report Date: 03/08/2023
Date Signed: 04/04/2023 02:25:45 PM

Document Has Been Signed on 04/04/2023 02:25 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SEA BREEZE MANORFACILITY NUMBER:
197803555
ADMINISTRATOR:VERGAL AGATEPFACILITY TYPE:
740
ADDRESS:3240 PINE AVETELEPHONE:
(562) 997-0906
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 6CENSUS: 3DATE:
03/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Vergal AgatepTIME COMPLETED:
01:30 PM
NARRATIVE
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On 03/08/2023, Licensing Program Analysts (LPAs) Lizeth Villegas, Felisa Shirley and
LPM Janae Hammond conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with administrator Vergal Agatep and explained the purpose of today’s visit. The facility is licensed to operate for six(6) non-ambulatory/ambulatory residents ages 60 and above. Facility may retain three (3)hospice residents.

The facility is a single-story structure located in a residential neighborhood. Facility consists of the following: four (4) resident's rooms, one (1) staff bedroom, one (1) common bathroom, two (2) private bathrooms and one (1) private half bathroom in room five (5), a living area, dining area, kitchen, outside covered patio area and an attached garage.

LPAs and administrator toured the physical plant, there were no obstructions on the premises. All rooms were inspected; beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational, water temperatures measured 111 F to 114 F.

LPA observed the facility to be sanitary and appropriately furnished at the time of 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 sufficient perishable and non-perishable food available maintained properly. The facility has two (2) fire extinguisher that were charged, smoke detectors, and carbon monoxide were operable. LPA Villegas reviewed Medication Administration Records (MAR) which revealed to be accurate and maintained in order. A working landline is operable with (1) one cordless telephone in the living room and (1) one cordless telephone located in the kitchen.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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Document Has Been Signed on 04/04/2023 02:25 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/08/2023 at 11:31 AM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEA BREEZE MANOR
FACILITY NUMBER: 197803555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as resident 3 did not have a light bulb in lamp which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2023
Plan of Correction
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Administrator to ensure operating bulb is installed and submit proof to LPA by POC due date.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as a small roach was observed moving in one of the kitchen cabnits which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Administrator shall reach out to pest control on a plan of treatment to treat facility and submit proof to LPA by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/04/2023 02:25 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/08/2023 at 11:31 AM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEA BREEZE MANOR
FACILITY NUMBER: 197803555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the last fire drill was conducted in 2020 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2023
Plan of Correction
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Administrator shall conduct a fire drill in compliance to title 22 reulations and submit proof to LPA by POC date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview , observation and record review, the licensee did not comply with the section cited above as resident number 3 has half bedrails, LPA did not observe a phsicians order which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2023
Plan of Correction
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Administrator shall reach out to physician to obtain physician order for half bedrails and submit dicumentation to
LPA by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2023 02:25 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/08/2023 at 11:51 AM
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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SEA BREEZE MANOR
FACILITY NUMBER: 197803555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)


This requirement is not met as evidenced by: Care for persons with dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as the auditory alram in bedrooms 1,2, 3 and 5 were not operable in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2023
Plan of Correction
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Administrator shall ensure that all auditory alarms are operable and self certified by POC due date
Type B
Section Cited
CCR
87506(a)


Resident records (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requrement is not met by.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 3 our of 3 resident records were incomplete, residents records not located in secure central location and are accessible to the public which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Administrator shall ensure all resident records are complete and stored in central secured location by poc due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SEA BREEZE MANOR
FACILITY NUMBER: 197803555
VISIT DATE: 03/08/2023
NARRATIVE
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During todays visit the following deficiencies were observed:

· LPA observed auditory alarms in rooms one (1), two (2) and five (5) were not operational at the time of visit
· LPA observed small roach in kitchen cabinet
· LPAs reviewed 3 of 3 residents records and all three records were incomplete, resident number one (1) was missing pre appraisal, needs for service plan and blank consent forms. Resident two (2) had blank consent form, needs for service plan. Resident three (3) was missing pre appraisal, needs for service plan and blank consent forms
· LPA reviewed resident number three (3) and did not observed physician orders for half bed rails
· LPA reviewed fire drill log and was informed by administrator that the last fire drill was conducted in 2020

Advisory Notes - Technical Assistance was issued, please see LIC9102-AN.

Deficiencies cited under California Code of Regulations title 22, division 6, chapter 8 are being cited on the attached LIC 809 D

An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to
Vergal Agatep.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC809 (FAS) - (06/04)
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