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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004792
Report Date: 06/03/2021
Date Signed: 06/03/2021 03:37:31 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:FOUNTAINS AT THE SEA BLUFFS, THEFACILITY NUMBER:
306004792
ADMINISTRATOR:TERRY BROWNFACILITY TYPE:
740
ADDRESS:25421 & 25401 SEA BLUFFS DRIVETELEPHONE:
(949) 443-9543
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:88CENSUS: 62DATE:
06/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Terry Brown and Andrea FurchTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Executive Director Terry Brown and explained the reason for the visit. Program Director Andrea Furch was present as well.

At 1:15 PM, LPA toured the facility with Program Director Andrea Furch. Facility has 62 residents in care during today's visit. LPA observed residents relaxing in common areas of the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes an electronic visitor sign in sheet as well as a self temperature taking station. Visitors and staff are given a sticker to place on their person after taking temperatures and signing in. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. LPA reviewed the mitigation plan as well as the facility's Covid-19 prevention plan. LPA observed ample emergency food and water as well as multiple first aid kits throughout the facility. Facility has sanitation stations spread out through the common areas. LPA observed a shaded outside visitation area. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. Facility rooms are currently single occupancy.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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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