306006172-9-2-2022-22-AS-KLYN-CHVQAH-20220902115958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006172
Report Date: 09/02/2022
Date Signed: 09/02/2022 03:26:57 PM

Document Has Been Signed on 09/02/2022 03:26 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:	FOUNTAINS AT THE SEA BLUFFS, THE		FACILITY NUMBER:	306006172
ADMINISTRATOR:	BROWN, TERRY		FACILITY TYPE:	740
ADDRESS:	25421 & 25401 SEA BLUFFS DRIVE		TELEPHONE:	(949) 234-3000
CITY:	DANA POINT	STATE: CA	ZIP CODE:	92629
CAPACITY:	88	CENSUS: 73	DATE:	09/02/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Greg Case and Andrea Furch		TIME COMPLETED:	12:15 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) Kimberly Lyman made an announced visit to conduct a pre-licensing inspection. LPA identified herself and discussed the purpose of the visit with Executive Director Greg Case. Program Director Andrea Furch was present as well. An initial application to operate a Residential Care Facility for the Elderly was received by CCL for a capacity of seventy eight non-ambulatory and ten bedridden residents. Facility has a covid screening area in the entrance of the facility. LPA observed ample PPE supply in the facility. LPA Lyman along with Executive Director and Program Director toured the facility at 9:15 AM and observed the following: Structure: Facility is composed of three different living areas, The Inn, the Terrace and the Gardens as well as independent living. The Inn and Terrace are assisted living and the Gardens is for Memory Care. Facility is three stories with a gated entrance. Facility has a library, salon, multiple activity areas, movie theater, computer lab and Wellness center. Common Areas: Adequate seating is available in both memory care and assisted living areas. Bedrooms Residents: Rooms are single and double occupancy. All rooms are equipped with appropriate lighting, furnishings 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. Facility has sanitizer/ soap in the restrooms. Linens & Hygiene Supplies: Facility has ample bedding and towels for residents in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has a dining area for independent resident, assisted living and memory care residents. LPA toured the main and auxiliary kitchens. Facility has ample 2 day perishables and 7 day non-perishables. Freezers and refrigerator temperatures are monitored daily and LPA observed documentation. Smoke Detectors: Smoke detectors/ carbon monoxide detectors tested operational during today's visit. Facility self tests smoke detectors every 90 days and an outside company, Johnson Control comes in for additional fire testing. Fire extinguishers are mounted and charged. Appliances: Kitchen appliances as well as washers and dryers are clean and operational. Continued on LIC 809C DATED 09/02/2022.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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: FOUNTAINS AT THE SEA BLUFFS, THE	FACILITY NUMBER: 306006172
	VISIT DATE: 09/02/2022

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Toxins/ Sharps: Facility has for toxins and sharps secured. Water Temperature: Tested and recorded between 95.9 and 121.2 degrees F. in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water in the facility as well as emergency incontinence supplies. Medications, First-Aid Kit & Book: Facility has multiple first aid kits which contained required items. Medication is stored and locked in medication charts. Facility uses a medication administration record. Resident & Staff File: Records are stored in medication rooms. Reading Material, Games, and Equipment: LPA observed multiple posted activity schedules with activities such as exercise, arts and crafts and outings in the community. Outside areas: LPA observed multiple outdoor shaded areas for visiting. Fire Clearance: Approved for seventy eight non-ambulatory residents and ten bedridden residents on 03/30/2022. Memory care is approved for delayed egress.

During the visit, LPA observed the following:

Water temperature is out of compliance. Please adjust water temperature to be between 105 and 120 degrees F.

During the visit, LPA consulted with Executive Director on the importance of open and responsive communication with the department.

Component III waived during visit as Executive Director is an experienced Administrator. Facility is not ready to be licensed. Licensee to contact LPA when corrections have been made.

Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

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