306001675-1-31-2024-22-AS-KLYN-CZYUWH-20240130145645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001675
Report Date: 01/30/2024
Date Signed: 01/31/2024 07:21:53 AM

Document Has Been Signed on 01/31/2024 07:21 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SEAVIEW CARE HOME II		FACILITY NUMBER:	306001675
ADMINISTRATOR:	RENE LAFIGUERA		FACILITY TYPE:	740
ADDRESS:	2827 CALLE GUADALAJARA		TELEPHONE:	(949) 218-5719
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92673
CAPACITY:	6	CENSUS: 5	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Cha Chua and Mercy Ang		TIME COMPLETED:	03:15 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 Seaview Care Home II. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Cha Chua. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents present. There are 2 residents on hospice during today's visit. Mercy Ang has an Administrator Certificate expiring on 11/25/2024. Administrator Mercy Ang arrived during the visit. LPA Lyman along with Caregiver Cha Chua toured the facility at 12:55 PM. Facility appears to be clean, safe, and sanitary. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of five resident bedrooms, three resident bathrooms, one shared hall bathroom, staff room, living room, dining room, and kitchen. At 12:55 PM, LPA observed the garage door is propped open with a chair and cleaning supplies as well as rust oleum is unsecured (photo). LPA observed the staff room is unlocked with prescribed medications and over the counter medications unsecured. 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 115.1 and 120.5 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 1:15 PM, LPA observed unsecured sharps and cleaning supplies in the kitchen (photo). Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents as well as a fenced, empty pool. LPA observed emergency water supply on-site. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted. Facility provides activities in the form of music and exercise. CONT ON LIC 809C DATED 01/30/2024.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: SEAVIEW CARE HOME II	FACILITY NUMBER: 306001675
	VISIT DATE: 01/30/2024

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
26
27
28
29
30
31
32

At 1:30 PM, LPA reviewed five resident files and two staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of health screen/TB, criminal record clearance and required training. At 2:00 PM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited monthly by staff RN. Medications are being administered per physician order.

Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/31/2024 07:21 AM - It Cannot Be Edited

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: SEAVIEW CARE HOME II	FACILITY NUMBER: 306001675
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

he following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed multiple occurrences of unsecured medications, cleaning supplies and sharps. Facility has four residents with Dementia. This poses an immediate health, and safety risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	Licensee to secure noted items and forward proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3