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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004792
Report Date: 03/21/2022
Date Signed: 03/21/2022 03:45:43 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220316154957
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:
03/21/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Andrea Furch and Donna EnriquezTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Facility staff are not wearing masks appropriately.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kimberly Lyman and Edward Tapia conducted an unannounced visit for the purpose of initiating a complaint investigation. LPAs were greeted and granted entry into the facility by Program Director Andrea Furch and explained the reason for the visit. Clinical Nurse Director Donna Enriquez was present as well.
During the visit, LPAs toured the facility and interviewed staff. Regarding the allegation that facility staff are not wearing masks appropriately, the investigation revealed the following: LPAs interviewed Program Director who confirmed Staff 1 (S1) has been observed with mask pulled down. Program Director has addressed the issue with the staff. S1 confirms loosening the mask and wearing the mask appropriately "most of the time". Both S1 and Program Director indicate S1 has health issues which make the mask uncomfortable. LPAs toured the facility and did not observe any other staff without masks. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided along with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 22-AS-20220316154957
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FOUNTAINS AT THE SEA BLUFFS, THE
FACILITY NUMBER: 306004792
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2022
Section Cited
CCR
87468.1(a)(2)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This req is not being met as evidenced by:
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Licensee to conduct a staff in-service on proper mask wearing and forward proof to LPA by POC due date.
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Based on interviews conducted, S1 has been observed not wearing a mask properly. This poses a potential health, safety and personal rights risk to residents 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
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