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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004792
Report Date: 07/19/2022
Date Signed: 07/19/2022 11:14:06 AM


Document Has Been Signed on 07/19/2022 11:14 AM - 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: 62DATE:
07/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Andrea Furch and Greg CaseTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on a death report received by Community Care Licensing (CCL) on 07/15/2022. LPA met with Program Director Andrea Furch and explained the reason for the visit. Executive Director Gregory Case was present as well during the visit.

Death report dated 07/09/2022 indicated that Resident 1 (R1) was discovered by staff slumped over the resident's toilet at approximately 4:42 AM, unresponsive with no pulse. R1 had no visible injuries. 911 called and paramedics and law enforcement arrived at which time R1 was declared deceased. Facility investigation revealed the resident had called for assistance around 3:45 AM and had requested water. Responding staff indicated R1 was emotional when the staff arrived but no physical concerns to be noted. R1 had a "Do Not Resuscitate" order on file. Per physician report dated 04/29/2021, R1 was diagnosed with Hypertension, Diabetes, and Atrial Fibrillation. Resident was independent and managed own finances and medication. Program Director as well as Director of Nursing indicate R1 had a long standing skin cancer diagnosis and had just had surgery on 07/06/2022. R1 had an ongoing battle with skin cancer resulting in many regular surgeries, sometimes monthly. Facility to forward a copy of death certificate to LPA upon receipt.

During the visit, LPA toured the facility as well as R1's room. LPA observed residents relaxing in the library area of the facility. No health and safety violations noted.


No citations observed during today's visit. 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: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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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