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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803555
Report Date: 03/21/2024
Date Signed: 03/21/2024 10:51:09 AM


Document Has Been Signed on 03/21/2024 10:51 AM - 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:
197803555
ADMINISTRATOR:VERGAL AGATEPFACILITY TYPE:
740
ADDRESS:3240 PINE AVETELEPHONE:
(562) 997-0906
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:6CENSUS: 3DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Director Vergal AgatepTIME COMPLETED:
11:15 AM
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On 03/21/2024, Licensing Program Analysts (LPAs) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Vergal Agatep and explained the purpose of today’s visit. The facility is licensed to operate for six(6) non-ambulatory/ambulatory clients ages 60 and above. Facility may retain three (3)hospice clients. Current facility census is 3, annual fees are current, liability insurance is active.

The facility is a single-story structure located in a residential neighborhood. Facility consists of the following: four (4) client rooms, one (1) staff bedroom, one (1) common bathroom, two (2) private bathrooms and one (1) private half bathroom in room five (5), a living area, dining area, kitchen, outside covered patio area and an attached garage that houses a washer and dryer, an additional refrigerator, canned goods and also serves as storage space. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, non slip mats and grab bars observed, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients. Auditory alarms observed and are operational, a land line was observed. There are no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 2 client records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire was conducted on 12/10/23, 3 fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational.

Exit interview conducted with Vergal Agatep, and a copy of this report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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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