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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320362
Report Date: 06/13/2023
Date Signed: 06/13/2023 11:46:08 AM

Document Has Been Signed on 06/13/2023 11:46 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SEA BREEZE MANORFACILITY NUMBER:
198320362
ADMINISTRATOR:HARRIS, SONNYFACILITY TYPE:
740
ADDRESS:30429 CALLE DE SUENOSTELEPHONE:
(424) 202-9813
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 0DATE:
06/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Sonny Harris, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Ana Soto conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) on 02/15/23 for an initial license for Residential Care For Elderly 60 years and above. The requested capacity is for (6) residents, (0) ambulatory, (5) non-ambulatory, (1) bedridden. Structure: Facility is a (4) bedroom, one (2) full bathroom, 3 bedrooms for residents and one for office, full storage room, single story house with small front porch with small ramp, big back yard with covered porch with ramp, and attached 2 car garage. The facility is a white stucco and has red title roof. Front yard landscape is in good condition. The back patio has umbrella, table and chairs, sofa, 2 storage sheds with extra water. washer/dryer area. Signal System: Signal system in facility. Bedroom Residents: There shall be no more than two residents per bedrooms. 3 Bedrooms are designated for shared bedrooms properly equipped with regulation guidelines of one bed, one chair, one night stand, one lamps and overhead lighting. Bedroom Staff: No room will be used for awake staff. Bathrooms: 1 full bathroom located in the north side of facility next to the 3 bedrooms and 2nd bathroom is located inside bedroom #1, both have working toilets and wash basins. Bathrooms also contain grab bars, folding bench, and non-skid mats, and trash cans with lids. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in hallway closets, and laundry area cabinet. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in the north hallway. Facility has a land line telephone located in bedroom #1 with router which the phone is available in the office . 2 Fire extinguishers, one 4A60BC mounted in laundry area, and the second 4A60BC is the kitchen mounted on the wall next to the back door which is labeled, they are tagged with current annual checks.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SEA BREEZE MANOR
FACILITY NUMBER: 198320362
VISIT DATE: 06/13/2023
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Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen, and consists of the following: 2 day perishables, and 7 week non-perishables. Smoke Detectors: There are 8 hard wired smoke detectors, and 1 battery operated carbon monoxide detector located in the laundry area which are operational. Appliances: Stove, dishwasher, microwave, and washer/dryer, refrigerator are in working condition. There is a freezer in the garage. The residence is equipped with central air and heat. Toxins: Cleaning supplies, and toxins are stored in two location: locked cabinet inside the laundry area and in the kitchen cabinet below the sink. Water Temperature: Water was tested in bathrooms and kitchen sink within 111.6 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in the office with lock. A first-aid kit has been inspected which has at least the following: thermometer, tweezers ,scissors, antiseptic, bandages, gauze and current first aid manual, which is located in the kitchen cabinet with medications, it is locked and available for staff use. Resident & Staff Files: Designated area for files will be located in the office in a locked cabinet. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. Fire Clearance: Fire clearance does indicate delayed egress and locked perimeter. Component III: Waived at the time of Pre-Licensing.

No corrections needed.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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