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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320362
Report Date: 07/18/2024
Date Signed: 07/18/2024 04:43:19 PM

Document Has Been Signed on 07/18/2024 04:43 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SEA BREEZE MANORFACILITY NUMBER:
198320362
ADMINISTRATOR/
DIRECTOR:		HARRIS, SONNYFACILITY TYPE:
740
ADDRESS:30429 CALLE DE SUENOSTELEPHONE:
(424) 202-9813
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 0DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:02 AM
MET WITH:Sonny Harris, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:03 PM
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On 07/18/2024 Licensing Program Analyst (LPA) Mario Leon held an unannounced, required, one (1) year visit to the above-mentioned facility using the CARE tools. LPA was met by Sonny Harris, Administrator (S1), and the purpose of the visit was explained.
The facility is licensed to operate for six (6); of which one (1) may be bedridden, four (4) non-ambulatory and one (1) ambulatory elderly adult(s), aged 60 and over. On 10/16/2023 the department approved the above-mentioned facility to retain two (2) hospice residents.
The facility is a single-story house, located in a residential neighborhood which consists of the following: five (5) bedrooms, and two (2) full bathrooms. There is one (1) living room, one (1) dining room, kitchen, washer/dryer area and an outside shaded area with umbrella, table and chairs. There is an attached two (2)-car garage. Of the five (5) bedrooms, four (4) of the bedrooms are reserved for residents and one (1) bedroom is used as the staff room. In addition, there is a one (1) shed located in the backyard.
LPA and Administrator (S1) toured the inside and outside of the facility. All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, with adequate lighting and sufficient toiletries were accessible to clients and were observed. The water temperature properly measured between 105 - 120 degrees F, within title 22 regulations.LPA observed the facilities screens to be in need of repair throughout the facility. See LIC809D.
Food supply was checked and a 7-day of non-perishable and 2-day supply of perishable foods were adequately stocked during the time of today's visit. Carbon monoxide/Smoke detectors were observed and operational. Fire extinguishers were fully charged as of 07/12/2023, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility fire drill was conducted on 07/01/2024. LPA reviewed the facility disaster plan and the facility disaster plan was current and in compliance with Title 22.
Report Continues, see LIC809C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SEA BREEZE MANOR
FACILITY NUMBER: 198320362
VISIT DATE: 07/18/2024
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An audit of residents #1-#5 (R1-R5) service files and medication administration record (MAR) and
staff #1-#4 (S1-S4) personnel files revealed to be complete.

There was one (1) deficiency cited during today's visit, see LIC809D. There has been one (1) Technical Advisory, Violation, cited during today's visit, see LIC9102-TV.

An exit interview was held with Sonny Harris, Administrator, and a copy of the facilities' appeal rights, LIC809D, LIC9102-TV and this report has been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/18/2024 04:43 PM - It Cannot Be Edited


Created By: Mario Leon On 07/18/2024 at 04:27 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SEA BREEZE MANOR
FACILITY NUMBER: 198320362

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation screens shall be replaced to repair tears and to keep screen frames "squared" to fit windows appropriately, the licensee did not comply with the section cited above in multiple windows and sliding doors throughout the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Administrator and LPA have agreed that the screens shall be replaced and the screen frames to be "squared" to fit all windows as observed together. Administrator will provide photo/video evidence to LPA at Mario.Leon@DSS.CA.GOV on or prior to the POC due date, which is 07/26/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024


LIC809 (FAS) - (06/04)
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