306006345-12-19-2025-22-AS-KLYN-DPHU8C-20251219142120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006345
Report Date: 12/19/2025
Date Signed: 12/19/2025 02:21:31 PM

Document Has Been Signed on 12/19/2025 02:21 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SEA BLUFFS, THE		FACILITY NUMBER:	306006345
ADMINISTRATOR/ DIRECTOR:	BRENT BROADHURST		FACILITY TYPE:	740
ADDRESS:	25421 AND 25401 SEA BLUFFS DR		TELEPHONE:	(949) 234-3000
CITY:	DANA POINT	STATE: CA	ZIP CODE:	92629
CAPACITY: 88		CENSUS: 73	DATE:	12/19/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:31 PM
MET WITH:	Brent Broadhurst		TIME VISIT/ INSPECTION COMPLETED:	01:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to deliver findings on an investigation conducted by the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. On August 25, 2025, the Department received an incident report regarding Resident 1 (R1). The incident report dated August 21, 2025, reported R1 was found on the floor in the resident’s room complaining of severe pain and was transferred to Mission Hospital. A computerized tomography (CT) scan was done at the hospital and revealed a right-sided subdural hematoma along with a left-sided subarachnoid hematoma. During the course of the investigation, the Department interviewed staff, residents and witnesses as well as reviewed and obtained documentation such as medical records and death report. Per physician report dated May 20, 2025, R1 is diagnosed with Mild Cognitive Impairment and is non-ambulatory using a walker for ambulation. Facility assessment dated July 31, 2025, lists R1 as a moderate fall risk. Service plan dated January 11, 2025, indicates that R1 requires a fall management program. Director of Health Services states R1 was checked four times per shift due to the fall risk, but the facility does not document the checks. The resident had a prior fall reported to the Department on March 04, 2025. Per facility staff interviewed, the resident did not sustain any long term changes in condition following the fall and was still able to ambulate and transfer independently while utilizing a walker. On August 21, 2025, around 12:23 PM, R1 was observed by staff who had entered the room to advise it was time for lunch. R1 reported feeling dizzy. Staff reported R1 was left sitting in their recliner when staff had exited to bring R1 their lunch. When the staff returned two minutes later, R1 was on the ground with the resident’s head leaning on the dresser. 911 was called and resident was transported to the hospital. At the hospital, the R1’s condition deteriorated CONTINUED ON LIC 809C DATED 12/19/2025

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEA BLUFFS, THE	FACILITY NUMBER: 306006345
	VISIT DATE: 12/19/2025

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due to the brain bleed. R1 had surgery on August 24, 2025, to release pressure due to the bleed, but the resident subsequently passed on August 25, 2025. The Orange County Coroner’s office conducted an investigation, and listed the death as accidental. Per the Coroner’s report, R1’s primary cause of death is listed as traumatic brain injury, sustained days prior to resident’s death with the secondary cause as fall, same level, sustained days prior to the resident’s death. Per the Department’s Interview with Orange County Coroner, there were no concerns of abuse, neglect, drugs, or alcohol. The Department interviewed R1’s primary care physician who stated that he did not believe the facility could have done anything different to prevent the fall and the facility does an excellent job of caring for residents. R1’s family member confirms satisfaction with resident’s care. Based on record review and interviews conducted, there was insufficient evidence to prove that the facility was neglectful or demonstrated a lack of care which led to the questionable death of the resident. Therefore, the allegation is deemed unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

LIC809 (FAS) - (06/04)

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