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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006146
Report Date: 12/07/2024
Date Signed: 12/07/2024 04:44:09 PM

Document Has Been Signed on 12/07/2024 04:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SEA CLIFF ASSISTED LIVINGFACILITY NUMBER:
306006146
ADMINISTRATOR/
DIRECTOR:		CLARK, TAYLORFACILITY TYPE:
740
ADDRESS:18851 FLORIDA STREETTELEPHONE:
(714) 847-3999
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY: 84CENSUS: 61DATE:
12/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Nisha KoiralaTIME VISIT/
INSPECTION COMPLETED:
04:07 PM
NARRATIVE
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On 12/07/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Med-Tech Nisha Korala who contacted the Administrator Taylor Clark by telephone. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (84) ambulatory, of which (44) non-ambulatory elderly adults ages 60 and above. The facility is approved for (20) hospice residents. Currently, the facility has (1) resident in hospice care.

The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (42) resident bedrooms, (42) resident bathrooms, a med room, a conference room, a dining room, a laundry room, business offices, a kitchen, (3) storage rooms, a staff bathroom, outdoor patio, a salon, and an employee lounge.

LPA Dabuet and Clark toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #152, #159, #164, #174, #203, #206, #214 and #218. Bathrooms were operational with water temperature measured at 105.2 – 107.9 degrees F. A comfortable temperature was maintained in the facility at 70 - 74 degrees F.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately.

Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. Disaster Drill/Evacuation Drill/Fire Drill are conducted monthly with records of !1/12/24 being the last drill. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SEA CLIFF ASSISTED LIVING
FACILITY NUMBER: 306006146
VISIT DATE: 12/07/2024
NARRATIVE
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu.

LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#6 (S1-S6) personnel files were maintained. The facility is current in CCLD annual fees. The administrator certificate for Taylor Clark #6013718740 2/8/2023 - 3/8/2025. The facility has a Liability Insurance Certificate valid with policy #B1881S240359 01/01/24 -01/01/25. The facility as current Surety Bond.

DEFICIENCIES:
· Resident #7 and #8 (R7-R8) are administered diabetic injection insulin daily by a non-appropriately skilled professional.
· Criminal Clearance Transfer Association for staff #1-#5 (S1-S5). No Criminal Clearance Transfer Request LIC 9162 on file or revealed on CDSS Guardian Background System.
· Staff #2-#5 (S2-S5) did not have current CPR/First Aid Certificate on file.
· Room #164 had a sink cabinet door broken/require repair.
· Room #174 and #218 had sharp scissors accessible to residents in care.
· Room #206 had cleaning powder bleach accessible to residents in care.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D).

An exit interview conducted with the Taylor Clark, and a copy of the report is provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2024 04:44 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/07/2024 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SEA CLIFF ASSISTED LIVING
FACILITY NUMBER: 306006146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87629(a)(b)(1)
87629(a)(b)(1)- (a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section. LPA identified resident #7 & #8 were administered diabetic insulins injections by a non- appropriately skilled professional staff daily. This violation which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Licensee will ensure will review regulation 87629 regarding the appropriate skilled professional to administer injections. The adminstrator will submit documentation and has read the regulation and how to comply moving forward. Proof of correction will be sent to LPA by email: ernand.dabuet@dabuet@dss.ca.gov by POC date.
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified staff #1-#5 (S1-S5) not have criminal record clearance transfer. Staff did not have an LIC 9162 on file nor transferred on CDSS Guardian. This violation which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Licensee will ensure all staff have criminal clearance transfer prior to working at the facility. Staff #1-#5 (S1-S5) according to CDSS Guardian is not associated to this facility. Licensee will associate staff #1-#5 (S1-S5)by POC due date. Send proof of correction by email to ernand.dabuet@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2024 04:44 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/07/2024 at 02:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SEA CLIFF ASSISTED LIVING
FACILITY NUMBER: 306006146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed (1) cleaning solution "clorox bleach and (2) sharp scissors in resident rooms accessible to residents in care. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2024
Plan of Correction
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Licensee will ensure to adhere to Title 22 87309 (a) and ensure all toxic and hazardous items are kept in a locked storage compartment and not accessible to residents in care. Proof of correction must be sent to LPA at ernand.dabuet@dss.ca.gov.
***Corrected during visit 12/7/24***
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/07/2024 04:44 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 12/07/2024 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SEA CLIFF ASSISTED LIVING
FACILITY NUMBER: 306006146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified bathroom cabinet sink with a missing/brokern door in resident's room #164. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/21/2024
Plan of Correction
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Licensee will ensure to adhere to Title 22 87303 Regulations and to ensure all bathing facilities shall maintained in operating condition. Licensee agreed to have the sink cabinet door/replaced or repaired by POC date. Proof of correction must be sent to LPA at ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Staff #2 -#5 did not have First Aid/CPR certificate on file. This violation which poses a potential health, safety, or personal rights risk to persons in care
POC Due Date: 12/21/2024
Plan of Correction
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Licensee will ensure all facility staff must have the mandatory First Aid/CPR Training completed. As plan of correction, administrator will send proof of completed First Aid/CPR will be sent to LPA via email: ernand.dabuet@dss.ca.gov before POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2024


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