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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006146
Report Date: 08/05/2025
Date Signed: 08/05/2025 03:57:59 PM

Document Has Been Signed on 08/05/2025 03:57 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 LIVINGFACILITY NUMBER:
306006146
ADMINISTRATOR/
DIRECTOR:		CLARK, TAYLORFACILITY TYPE:
740
ADDRESS:18851 FLORIDA STREETTELEPHONE:
(714) 847-3999
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY: 84CENSUS: 63DATE:
08/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Monet Young and Jaleesa ChavezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to Sea Cliff Assisted Living. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 84 ambulatory of which 44 may be non-ambulatory (first floor). Facility has an approved hospice waiver for 20 residents and the facility currently has 5 residents on hospice care. Taylor Clark has an administrator certificate expiring on 03/08/2027. Assistant Administrator for the skilled nursing side Jaleesa Chavez arrived during the visit.

LPAs Lyman and Mendivil along with Assistant Administrator Chavez toured the facility at 9:18 AM. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility consists of one main building housing assisted living residents. LPAs observed kitchen, dining room, library and outside patios. Resident rooms had the required furnishings in rooms. At approximately 9:40 AM, LPAs observed discoloration on walls and door in room 154. LPAs observed discoloration on wall in room 221 and sink is backing up in room 210. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 108 and 111 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Staff responded within 8 minutes for emergency cord pull. Common areas were clean and clear of hazards. First aid kit had all the required elements including tweezers, thermometer, and scissor as well as a first aid manual. LPAs observed no toxins unsecured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. CONTINUED ON LIC 809C DATED 08/05/2025

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/05/2025
NARRATIVE
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LPAs observed an evacuation chair in each stairwell. Smoke detectors and carbon monoxide detectors are tested monthly in-house. Fire inspections are conducted by an outside company, Alarm and Sprinkler Company with the last inspection date of 06/16/2025. Fire extinguishers are fully charged. LPAs toured the outside grounds and there is multiple patio areas. LPAs observed ample emergency food and water. LPAs reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provides activities in the form of games, exercise, and crafts. LPAs observed residents participating in activities during the visit.
At 11:00 AM, LPAs reviewed resident and staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Three out of three residents with bed rails do not have corresponding physician orders for bed rails. Resident 1 (R1) is non-ambulatory per physician report dated 10/15/2024 and is residing on the second floor. Per facility license, non-ambulatory residents must be housed on the first floor. LPAs reviewed staff files. LPA observed three out of six staff files did not contain proof of required annual training. LPAs observed Staff #7 and 8 are on-site from the skilled nursing and do not have criminal record clearance. LPAs were provided copies of health screenings by a staff from the skilled nursing side which were determined to be falsified.
LPAs reviewed select medications during the visit. Medications are secured in a medication cart and facility uses an electronic medication administration record.

Based on the observations made during today’s visit, 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 as well as appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
Page: 9 of 9
Document Has Been Signed on 08/05/2025 03:57 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 08/05/2025 at 02:39 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. R1 is non-ambulatory per physician report and is residing on the second floor. Facility license indicates non-ambulatory residents must be on the first floor. This poses an immediate health and safety risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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Licensee to relocate R1 and forward proof to LPA by POC due date.
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two staff who are not criminally cleared and associated to the facility which poses an immediate health, safety or personal rights risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 08/06/2025
Plan of Correction
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Licensee to obtain criminal record clearance and forward proof to LPA by POC dye 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2025 03:57 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 08/05/2025 at 02:39 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. LPAs observed discoloration on walls and doors as well as a sink backing up which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Licensee to repair noted items and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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. LPAs observed sliding door screen in the dining room is in need of repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Licensee to repair/ replace screen and forward proof to LPA by 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2025 03:57 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 08/05/2025 at 02:39 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of six staff who do not have required training. Staff #2,3 and 6 do not have required training: 8 hours Dementia and 4 hours of postural supports, hospice and restricted conditions which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Licensee to provide training and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.

A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of three residents without physician orders for bed rails which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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Licensee to obtain physician orders for bed rails and forward proof to LPA by 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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Created By: Kimberly Lyman On 08/05/2025 at 03:00 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.50(a)(3)
Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPAs were provided falsified health screen documents and staff confirmed the documents had been falsified which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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Licensee to conduct an in-service on appropriate conduct and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2025 03:57 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 08/05/2025 at 03:03 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
ll facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. Facility does not have a designated back up administrator during today's visit and staff from the skilled nursing are assisting LPAs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
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2
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4
Licensee to forward an updated LIC 308 to LPA by 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


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Created By: Kimberly Lyman On 08/05/2025 at 03:06 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: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411
All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in five out of six without a health screen/ TB which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
1
2
3
4
Licensee to obtain health screening/ TB assesssment and forward proof to LPA by 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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Lyman
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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