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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004562
Report Date:
07/08/2021
Date Signed:
07/08/2021 02:48:05 PM
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:
SUNRISE OF SEAL BEACH
FACILITY NUMBER:
306004562
ADMINISTRATOR:
LUIS RODRIGUEZ
FACILITY TYPE:
740
ADDRESS:
3850 & 3840 LAMPSON AVE
TELEPHONE:
(562) 594-5788
CITY:
SEAL BEACH
STATE:
CA
ZIP CODE:
90740
CAPACITY:
261
CENSUS:
136
DATE:
07/08/2021
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
02:31 PM
MET WITH:
Luis Rodriguez
TIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an incident report submitted to Community Care Licensing (CCL) on 07/02/2021. LPA met with Executive Director Luis Rodriguez and explained the reason for the visit.
Incident report dated 06/30/2021 indicated Resident 1 (R1) was observed coming out of the resident's apartment with pants tied around the neck and verbalizing a desire to end the resident's life. 911 was called and R1 was sent out to Los Alamitos Medical Center. R1 is currently at Newport Bay Hospital and will transfer to a skilled nursing after treatment. Resident has a dual diagnosis of Dementia and Schizophrenia. Facility to reassess R1 for suitability in the facility as well as care levels.
Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Kimberly Lyman
TELEPHONE:
(714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE:
07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/08/2021
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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