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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006345
Report Date: 09/24/2024
Date Signed: 09/24/2024 02:53:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/18/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240918145738
FACILITY NAME:SEA BLUFFS, THEFACILITY NUMBER:
306006345
ADMINISTRATOR:LUTHER, ANDREAFACILITY TYPE:
740
ADDRESS:25421 AND 25401 SEA BLUFFS DRTELEPHONE:
(949) 234-3000
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:88CENSUS: 66DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Brent BroadhurstTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is falsifying resident records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA interviewed staff and witness as well as reviewed and obtained pertinent documentation such as facility form. Regarding the allegation that facility is falsifying resident records, the investigation revealed the following: Staff 1 (S1) was employed at the facility as the Memory Care Director. Facility form letter to physicians indicate S1 is an LVN. Review of California State Vocational Nursing Board does not have verification of licensure. S1 denies having an LVN license and indicates the form letter verbiage is an oversight. LPA conducted interviews with S2 and S3 and both deny any falsifying of resident physician reports. Document obtained by LPA indicate a conversation took place educating who can apporpiately fill out the physician report. Based on interviews conducted and record review, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, CONTINUED ON LIC 9099C DATED 09/24/24
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20240918145738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 BLUFFS, THE
FACILITY NUMBER: 306006345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2024
Section Cited
CCR
87207
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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This req is not being met as evidenced by:
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Licensee to remove the false statement on facility forms and forward proof to LPA by POC due date.
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Based on record review, Licensee failed to ensure no false or misleading statements were disseminated. Facility form letter states S1 is an LVN when in fact the staff is not an LVN. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240918145738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 BLUFFS, THE
FACILITY NUMBER: 306006345
VISIT DATE: 09/24/2024
NARRATIVE
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(Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3