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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602472
Report Date: 12/22/2022
Date Signed: 12/22/2022 03:12:42 PM

Document Has Been Signed on 12/22/2022 03:12 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SUN AND SEA ASSISTED LIVINGFACILITY NUMBER:
374602472
ADMINISTRATOR:ANNE OWENS STONEFACILITY TYPE:
740
ADDRESS:740 SEVENTH STREETTELEPHONE:
(619) 429-0633
CITY:IMPERIAL BEACHSTATE: CAZIP CODE:
91932
CAPACITY: 32CENSUS: 24DATE:
12/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Jhmel AgustinTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Tammer De Los Santos conducted an unannounced Case Management visit. LPA was allowed entry and discussed the purpose of the visit with Administrator Jhmel Agustin. LPA also met with Med Techs / Caregivers Richard Tibi and Santana Tellez. All staff that were encountered had current criminal record clearance.

Today's visit was in response to self-reported death of Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1]. R1 passed away on 12/15/2022 at the facility. LPA conducted interviews with staff and collected records.

No deficiencies were cited during today's visit.

An exit interview was conducted with Administrator Jhmel Agustin to whom a copy of this report and appeal rights (LIC9058 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tammer DeLosSantos
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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