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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005604
Report Date: 09/11/2023
Date Signed: 09/13/2023 09:26:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
02/15/2022 and conducted by Evaluator Jenifer Tirre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220215091853
FACILITY NAME:SEA CLIFF ASSISTED LIVINGFACILITY NUMBER:
306005604
ADMINISTRATOR:PAMELA JUNGEFACILITY TYPE:
740
ADDRESS:18851 FLORIDA STTELEPHONE:
(714) 847-3999
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY:0CENSUS: DATE:
09/11/2023
UNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff were not checking residents blood sugar
Resident was severely dehydrated
Staff did not notify authorized representative of residents change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jenifer Tirre attempted contacting Licensee for the purpose of delivering the findings on a complaint investigation via telephone due to facility Change of ownership on 7/6/2022. The investigation consisted of interviews with Sea Cliff Assisted Living staff, physician’s, and Resident’s family. The investigation also consisted of obtained medical records from Huntington Beach Fire/ Paramedic Records, Fountain Valley Hospital, Comfort Life Hospice and County of Orange Clerk Recorder Documents.

On 2/15/2022 the department received allegations that staff were not checking residents blood sugar, Resident was severely dehydrated, and Staff did not notify authorized representative of residents change in condition. The investigation was completed by the Department and revealed the following:
On 1/24/2022 the family of Resident 1 (R1) scheduled a meeting via phone with Facility Executive Director (ED) Pamela Junge to discuss importance of R1’s health condition and family’s concerns about continuation of administering insulin for R1’s diabetes.
CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20220215091853
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SEA CLIFF ASSISTED LIVING
FACILITY NUMBER: 306005604
VISIT DATE: 09/11/2023
NARRATIVE
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R1’s family and ED came to an agreement according to interviews regarding R1’s insulin medication and ED assured family that staff would check R1’s glucose levels twice a day as well as setting up insulin injection pen with proper dosage to hand over to R1 in order for R1 to administer insulin shot for themselves. Before being admitted to the facility, ED had suggested to family to place R1 on hospice. According to interviews ED recommended Comfort Life Hospice and family placed R1 under their care.

On 1/28/2022, R1 was transferred from Sea Cliff Skilled Nursing Facility (SNF) and admitted to Sea Cliff Assisted Living facility. Upon being admitted to the facility, R1 was placed on hospice services with Comfort Life Hospice. After being admitted to the hospice company, R1’s insulin medication was discontinued by the hospice attending physician without consulting R1’s Primary Care Physician or responsible party. From 2/5/22 to 2/7/22 R1’s family visited daily and noticed R1 was very lethargic and not eating or drinking well.

On 2/7/2022 a Comfort Life Hospice RN visited R1. During this visit R1’s family learned that R1’s Hospice Doctor discontinued insulin medication and glucose levels had only been checked once. The following day R1 went to the hospital at the request of their family. According to medical records reviewed, R1 arrived at Fountain Valley Hospital with an elevated blood glucose level of 521. Records indicated that R1 also had acute kidney injury due to dehydration. Records reviewed reported R1 was severely dehydrated and R1’s kidneys were shutting down by the time R1 arrived at hospital. R1 later passed away on 2/9/2022 while in the hospital.

Per an interview conducted with R1’s PCP, the PCP reported being unaware that R1 was transferred to an Assisted Living Facility and was placed on Hospice Care. R1’s PCP denied having knowledge of why R1’s insulin medication was discontinued. R1’s Death Certificate states R1’s cause of death was due to Sepsis, Renal failure and Diabetes Mellitus 11.

Based off information obtained the allegations Staff were not checking residents blood sugar, Resident was severely dehydrated, and Staff did not notify authorized representative of residents change in condition have met the preponderance of evidence standard, therefore the above allegation(s) are found to be SUBSTANTIATED.

The following is being cited per California Code of Regulations, Title 22, Division 6 Chapter 8.

A civil penalty is pending determination, per H&S Code Section 1569.49(e).



CONTINUED ON 9099C
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20220215091853
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEA CLIFF ASSISTED LIVING
FACILITY NUMBER: 306005604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2023
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care. The Licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by R1’s physician report dated 1/28/22 failed
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Facility closed and had change of ownership effective 7/6/2022. No plan of correction required at this time.
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 to disclose if R1 was able to Administer their own insulin or monitor their own glucose. Executive Director verbally promised R1’s responsible party on 1/24/2022 that facility staff would assist in R1 self-administering medications and help monitor glucose levels.Upon being
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Type A
CCR
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(Continued) placed on hospice orders were received to discontinue insulin and no orders were given to monitor glucose levels. R1’s responsible party was not made aware of the changes. This poses an immediate risk to the health & safety of residents in care.
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CCR
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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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20220215091853
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEA CLIFF ASSISTED LIVING
FACILITY NUMBER: 306005604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2023
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidence by medical records reviewed confirm that R1 was hospitalized with acute kidney injury
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Facility closed and had change of ownership effective 7/6/2022. No plan of correction required at this time.
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due to dehydration. Interviews conducted confirm prior to the hospitalization R1 had been refusing to eat and drink and appeared lethargic. This poses an immediate risk to the health & safety of residents in care.
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Type B
09/11/2023
Section Cited
CCR
87468.1(a)(8)
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Personal rights of residents in alll facilities
...shall have all of the following personal rights.To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. To have
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Facility closed and had change of ownership effective 7/6/2022. No plan of correction required at this time.
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communications to licensee from their representatives answered promptly & appropriately. This requirement is not met as evidence by R1’s insulin meds & glucose monitoring were discontinued upon hospice 1/28/22 without consulting R1's RP & PCP. ED failed to inform this poses potential risk to the health & safety or 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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20220215091853
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SEA CLIFF ASSISTED LIVING
FACILITY NUMBER: 306005604
VISIT DATE: 09/11/2023
NARRATIVE
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The facility has had a change of ownership effective 7/6/2022 . Attempts to reach Licensee Beach City Senior Living LLC. to conduct an exit interview were unsuccessful. A copy of this report will be certify mailed to the Licensee’s last known address.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5