306006146-6-15-2022-22-AS-JTIE-CFEU4F-20220615151506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006146
Report Date: 06/15/2022
Date Signed: 06/15/2022 03:15:13 PM

Document Has Been Signed on 06/15/2022 03:15 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:	SEA CLIFF ASSISTED LIVING		FACILITY NUMBER:	306006146
ADMINISTRATOR:	ROCHE, RYAN		FACILITY TYPE:	740
ADDRESS:	18851 FLORIDA STREET		TELEPHONE:	(714) 847-3999
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92648
CAPACITY:	84	CENSUS: 34	DATE:	06/15/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:37 AM
MET WITH:	Administrator, Ryan Roche		TIME COMPLETED:	03:25 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) Jenifer Tirre made an announced pre-licensing visit. LPA identified themselves and discussed the purpose of the visit with Administrator Ryan Roche, Director John Money, Wellness Director Taylor Clark, and Sand Piper Senior Living Treasurer Soon Burnham. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCL on 02/11/22. There are 34 residents in care during today's visit. LPA observed facility is following covid precaution guidelines. LPA Tirre along with Administrator, Director, Wellness Director, and Treasurer toured the facility at 11:00 AM and observed the following: Structure: Facility is a two story building housing 42 Rooms. Assisted Living rooms are both private room and double occupancy. Facility offers a library, dining room, as well as two outside patios. Living Room/ Dining Room: Adequate seating is available in the main dining room. Bedrooms Residents: All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has ample perishable and non perishable food supplies. LPA observed a posted menu with multiple choices for residents. Smoke Detectors: Facility has Carbon monoxide detectors were tested operational. Smoke detectors tested operational by City of Huntington Beach on 5/5/2022. LPA observed documentation of inspection. Facility has 7 Fire extinguishers, all fully charged and mounted. Toxins: Secured and inaccessible to residents in care. Water Temperature: LPA tested water temperature in 8 rooms. Water temperature recorded between 111.7 and 126.1 degrees F in tested bathrooms. Emergency Supplies: LPA observed ample emergency food and water stored onsite in facility storage. CONT ON LIC 809C DATED

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SEA CLIFF ASSISTED LIVING	FACILITY NUMBER: 306006146
	VISIT DATE: 06/15/2022

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LPA' observed the emergency disaster plan and facility has submitted the mitigation plan as well.Medications, First-Aid Kit & Book: LPA observed first aid kits and contained required elements. Medications are stored in locked medication carts. Facility uses digital medication administration record. Resident & Staff File: LPA reviewed resident files during the visit. Reading Material, Games, and Equipment: LPA observed the library room as well as posted activities in multiple locations. Outside areas: LPA observed two different outside shaded areas for residents. Fire Clearance: Approved for 62 ambulatory residents and 22 bedridden residents on 3/24/22. LPA observed the emergency chair adjacent to the staircase.

Licensee to address the following corrections by 6/22/22

Water temperature is out of compliance in the following rooms, 155, 156,174, and 208. Please adjust water to be in compliance.
Staff files need to be located in secure location on site
Let Us Know Poster is not regulation size, please have proper size poster 20x26 posted near entrance

The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.

Component III not conducted during visit due to facility Administrator currently running other licensed facilities.

An exit interview was conducted with Administrator and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022

LIC809 (FAS) - (06/04)

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