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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006172
Report Date: 09/11/2023
Date Signed: 09/11/2023 11:23:37 AM


Document Has Been Signed on 09/11/2023 11:23 AM - 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 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: 61DATE:
09/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gregory Case, Executive Director
Andrea Furch, Memeory Care Director		TIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Ruth Martinez made visit to this facility to conduct a case management visit. LPA arrived at facility was greeted and granted entry by receptionist. LPA met with Gregory Case, Executive Director and Andrea Furch, Memory Care Director and explained the nature of the visit.

LPA is conducting this visit as a follow up on an incident that was self reported an incident on September 08, 2023 regarding R1’s incident on September 02, 2023.

During today’s visit, LPA interviewed staff, toured the memory care unit and obtained copies of pertinent documents.

On September 02, 2023 at approximately 9:20am R1 walked out of the facility and into the community. A facility neighbor observed resident in the community and called local police department. Resident was picked up by police department and taken to nearest hospital for evaluation. At about 9:30am Police Department arrived to facility and notified them that R1 was at found out in the community and was taken to hospital for evaluation. Memory Care Director notified R1’s responsible party and went to hospital to pick up R1 for discharge and returned R1 to facility. R1 was returned to the facility with no injuries and has since had no further incidents or any concerns with the well being of resident. LPA did not observe any immediate and/or safety risks in or out of the facility.

This report was reviewed with facility representatives and a copy of the report was provided and left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
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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