306001675-1-16-2025-22-AS-FARS-DCYRK8-20250116120506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001675
Report Date: 01/16/2025
Date Signed: 01/16/2025 12:05:25 PM

Document Has Been Signed on 01/16/2025 12:05 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	SEAVIEW CARE HOME II		FACILITY NUMBER:	306001675
ADMINISTRATOR/ DIRECTOR:	RENE LAFIGUERA		FACILITY TYPE:	740
ADDRESS:	2827 CALLE GUADALAJARA		TELEPHONE:	(949) 218-5719
CITY:	SAN CLEMENTE	STATE: CA	ZIP CODE:	92673
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:55 AM
MET WITH:	Mercy Ang		TIME VISIT/ INSPECTION COMPLETED:	12:20 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	On this day Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents, with 3 residents on hospice. Administrator (AD) Mercy Ang arrived shortly to conduct facility tour. AD Ang has a certificate renewal in process which was received on 10/10/2024 . AD provided updated liability insurance that expires on 7/1/2025. LPAs along with Administrator Ang toured the facility at 8:15 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 5 resident bedrooms, living room, dining room, and kitchen as well as 4 restrooms and 1 staff bedroom. 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 107 degrees F and 117.8 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory alarms were operational during today's visit. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 11/10/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, music, and pet therapy. CONTINUED ON LIC 809C DATED 1/16/2025

Alisa Ortiz	TELEPHONE: (714) 287-4084
Fred Arias	TELEPHONE: (714) 703-2840
	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEAVIEW CARE HOME II	FACILITY NUMBER: 306001675
	VISIT DATE: 01/16/2025

NARRATIVE

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There is shaded outdoor seating for residents. At 8:40 AM, LPAs observed the exit gate is unable to close due to structural issues. LPAs observed the emergency food and water supply. LPAs reviewed five resident files and two staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medication Administration Record (MAR) is not updated daily.

Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred Arias	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/16/2025 12:05 PM - 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
ORANGE COUNTY RO, 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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and AD interview, the external exit gate does not close completely and it's jarred against the facility wall which poses a potential safety risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	AD to get proposals and HOA/city approval to repair/replace gate. AD to inform LPA once gate is operational.

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.

Alisa Ortiz	TELEPHONE: (714) 287-4084
Fred Arias	TELEPHONE: (714) 703-2840
	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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