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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004562
Report Date: 05/12/2023
Date Signed: 05/12/2023 03:54:13 PM


Document Has Been Signed on 05/12/2023 03:54 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SUNRISE OF SEAL BEACHFACILITY NUMBER:
306004562
ADMINISTRATOR:LUIS RODRIGUEZFACILITY TYPE:
740
ADDRESS:3850 & 3840 LAMPSON AVETELEPHONE:
(562) 594-5788
CITY:SEAL BEACHSTATE: CAZIP CODE:
90740
CAPACITY:261CENSUS: DATE:
05/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Sandra Robles, Business Office CoordinatorTIME COMPLETED:
04:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of citing a deficiency observed during the investigation of allegations made as part of complaint reference 22-AS-20230421101238.

On April 25, 2023, LPA requested and obtained resident records for resident R1. A Physician report dated June 1, 2021 was observed to be part of the records. A confirmed diagnosis of dementia is documented on the medical assessment. The resident was also noted to receive monthly medical follow-ups as well as frequent reassessments by a psychiatric nurse practitioner. However no other assessment was found in the records, as is required by the California Code of Regulations Section 87705 pertaining to the Care of Persons with Dementia.

One type B deficiency is observed per Title 22 regulations at this time. It is documented and cited in the attached LIC809-D form.

An amended version of form LIC9099-C created during the April 25, 2023 was also delivered during the visit as part of a sentence was missing in the original report.

An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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 05/12/2023 03:54 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: SUNRISE OF SEAL BEACH
FACILITY NUMBER: 306004562

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2023
Section Cited

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The California Code of Regulations Section 87705(c)(5) states that: "Each resident with dementia shall have an annual medical assessment (...) and a reappraisal done at least annually(...)". This requirement is not met as evidenced by:
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Resident R1 moved out of the facility on April 20, 2023 and a medical assessment was conducted by the new facility prior to admission. The Plan of Corrections is therefore considered to be cleared at the time of the present visit.
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Based on records reviewed at the facility, the most recent medical assessment conducted for resident R1 is dated June 1, 2021 with no additional reassessments. This constitutes a potential risk to the health, safety and personal rights of the individuals 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
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