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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801728
Report Date: 09/30/2021
Date Signed: 09/30/2021 06:29:59 PM

Document Has Been Signed on 09/30/2021 06:29 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SEA BREEZE MANORFACILITY NUMBER:
565801728
ADMINISTRATOR:ROSE MARIE LOPEZFACILITY TYPE:
740
ADDRESS:1511 OFFSHORE STREETTELEPHONE:
(805) 985-5995
CITY:OXNARDSTATE: CAZIP CODE:
93035
CAPACITY: 6CENSUS: 5DATE:
09/30/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Hermi Gonzales and Rose Marie LopezTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Deficiencies inspection at the facility today due to a violation observed during the complaint investigation of control #29-AS-20200803140639.

At 2:15 PM the LPA reviewed records for Staff #1 (S1) and Staff #2 (S2) which revealed S1's first aid and CPR training expired 9/25/21 and S2's first aid and CPR training expired 9/26/21.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted. Today's reports and appeal rights were reviewed and will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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Document Has Been Signed on 09/30/2021 06:29 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 09/30/2021 at 04:06 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SEA BREEZE MANOR
FACILITY NUMBER: 565801728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2021
Section Cited
CCR
87411(c)(1)

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87411 Personnel Requirements - General
(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
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The Administrator shall submit proof to CCL by 10/08/2021 that S1 and S2 have current first aid and CPR training.
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Based on record review, the licensee did not comply with the section cited above as S1 and S2 do not have current first aid and CPR training which poses a potential health and safety risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
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