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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006172
Report Date: 12/19/2022
Date Signed: 12/19/2022 02:13:46 PM


Document Has Been Signed on 12/19/2022 02:13 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:CASE, GREGORYFACILITY TYPE:
740
ADDRESS:25421 & 25401 SEA BLUFFS DRIVETELEPHONE:
(949) 234-3000
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:88CENSUS: 64DATE:
12/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Greg Case and Donna EnriquezTIME COMPLETED:
02:30 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 12/16/2022. 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.

Death report dated 12/05/2022 indicated Resident 1's (R1) private caregiver called staff for assistance. When staff responded, R1 was purple in color with no pulse or respirations. 911 was called and paramedics and coroner responded. R1 was pronounced deceased by coroner on-site. Per follow up with R1's physician, cause of death was cardiopulmonary arrest.

Per physician report, R1 is diagnosed with Lewy Body Dementia, Hypertension, and Chronic Obstructive Pulmonary Disease. Resident was currently not on hospice care. R1 had been on and off hospice care two times and a hospice consult was ordered on 12/05/2022. Resident was being seen by home health for wound care and the last visit was same day, 12/05/2022. Resident was being seen regularly by physician and last contact was 11/08/2022.

Facility to obtain a copy of the death certificate and forward to LPA upon receipt.



Based on the observations made during today's visit, no deficiencies are being cited.

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: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
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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