<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004792
Report Date: 06/13/2022
Date Signed: 06/13/2022 02:40:36 PM


Document Has Been Signed on 06/13/2022 02:40 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
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: 58DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Terry Brown and Andrea FurchTIME COMPLETED:
12:00 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
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. Facility consists of independent living, assisted living, enhanced assisted living and memory care units. Executive Director Terry Brown has an administrator certificate expiring on 01/28/2023.

At 10:14 AM, LPA toured the facility with Program Director Andrea Furch. Facility has 58 residents in care during today's visit with eleven on hospice care. 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 all required department postings. Facility has a mitigation plan as well as the facility's Covid-19 prevention plan. OC Fire Authority conducted a fire inspection on 04/19/2022 and Johnson Control tested smoke detectors on 10/25/2021. 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. Resident's participate in activities such as exercise, games, and outings in the community. 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 and double occupancy.
LPA consulted with Program Director on the importance of timely staff response to the emergency button in resident's rooms.
Based on the observations made during today’s visit, NO deficiencies are 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1