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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006345
Report Date: 12/23/2024
Date Signed: 12/23/2024 03:39:36 PM

Document Has Been Signed on 12/23/2024 03:39 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SEA BLUFFS, THEFACILITY NUMBER:
306006345
ADMINISTRATOR/
DIRECTOR:
BRENT BROADHURSTFACILITY TYPE:
740
ADDRESS:25421 AND 25401 SEA BLUFFS DRTELEPHONE:
(949) 234-3000
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY: 88CENSUS: DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Haley GmachTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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On this day Licensing Program Analysts (LPAs) Fred Arias and Andrea Mendivil made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 88 non-ambulatory residents of which 10 may be bedridden. Facility has an approved hospice waiver for 15 residents and the facility currently has 67 residents, with 7 residents on hospice. Maintanance Director (MD) Pedro Ucros and Assistant Administrator (AAD) Haley Gmach arrived shortly to conduct facility tour. AAD Gmach has a valid certificate that expires on 8/10/2025. AAD provided updated liability insurance that expires on 7/01/2025.

LPAs along with MD Ucros toured the facility at 8:30 AM with AAD Gmach joining shortly after. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 118.6 degrees F and 119.8 degrees F in checked restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPAs toured the kitchen on the first floor in memory care and observed sharps in a cabinet that was not locked. Continued on LIC 809-C dated 12/23/2024.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SEA BLUFFS, THE
FACILITY NUMBER: 306006345
VISIT DATE: 12/23/2024
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The first floor kitchen in memory care also had toxins under the sink that were not secured due to malfunctioning cabinet doors. MD stated cabinet doors would be replaced and secured during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Some perishable food in the assisted living area kitchen was expired including milk, salad dressing, beef, and fish. Pork patties were observed to be on a kitchen counter kept at room temperature. Smoke detectors are tested quarterly by an outside party with the latest test recorded on 4/17/2024. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility last conducted emergency drills on 7/31/2024. Outside grounds were toured. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, arts and crafts, and group movie watching. There is shaded outdoor seating for residents. LPAs observed the emergency food and water supply. LPAs reviewed three resident files, three staff files, and ADD file. All resident files reviewed contained required documentation including admission agreements, physician reports, and resident appraisals. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked office on each floor. Medications are being administered per physician order.

Based on the observations made during today’s visit, 2 deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2024 03:39 PM - It Cannot Be Edited


Created By: Fred Arias On 12/23/2024 at 02:57 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEA BLUFFS, THE

FACILITY NUMBER: 306006345

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based LPA observation, the licensee did not comply with the section cited above as cabinet below kitchen sink in memory care used to store toxins was not locked and secured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Facility corrected deficiency during today's visit.
Request Denied
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above. Perishible food such as milk, salad dressing, beef, and fish were found expired (photos taken). In addition, pork patties were found on a kitchen counter at room temperature which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Facility removed expired food from the kitchen during today's visit.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Fred Arias
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


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