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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006172
Report Date: 10/17/2022
Date Signed: 10/17/2022 02:19:10 PM


Document Has Been Signed on 10/17/2022 02:19 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, THEFACILITY NUMBER:
306006172
ADMINISTRATOR:BROWN, TERRYFACILITY TYPE:
740
ADDRESS:25421 & 25401 SEA BLUFFS DRIVETELEPHONE:
(949) 234-3000
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:88CENSUS: 65DATE:
10/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Greg CaseTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report submitted to Community Care Licensing on 10/14/2022. LPA was greeted and granted entry into the facility by Executive Director Greg Case and explained the reason for the visit. Clinical Nurse Director Donna Enriquez was present as well as Program Director Andrea Furch on the phone.

Death report dated 10/06/2022 indicated Resident 1 (R1) complained of pressure to the chest and staff called 911. Paramedics and Orange County Sheriff responded and R1 was unresponsive. R1 declared deceased and coroner declined to come out. Facility notified family and mortuary.

Per facility, resident had complained of feeling nauseous in dining room area and was escorted back to room by Program Director Andrea Furch. Resident vomited and complained of chest pressure. At this point, 911 was called. Resident initially did not want 911 called but facility called 911 due to the resident's symptoms. By the time paramedics arrived, the resident was unresponsive. Per physician report, R1 is diagnosed with hyperlipidemia, obesity, and vitamin B deficiency. Facility provided card for responding Deputy Sheriff. Facility to obtain death certificate and forward copy to LPA upon receipt.






Based on the observations during today's visit, no citations are noted. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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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