<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881077
Report Date: 04/20/2022
Date Signed: 04/20/2022 02:01:19 PM


Document Has Been Signed on 04/20/2022 02:01 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:SEA BREEZE HOMES OF EASTVALE LLCFACILITY NUMBER:
331881077
ADMINISTRATOR:LONG, MARIAM BFACILITY TYPE:
740
ADDRESS:5897 SPRINGCREST STTELEPHONE:
(714) 299-9634
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:6CENSUS: 4DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Miriam Long, AdministratorTIME COMPLETED:
02:15 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) Amy Goldenberg made an announced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA was met at the door by caregiver and granted entry into the home. LPA is informed that there are no COVID positive individuals in the home. The facility has an approved mitigation plan on file with this agency. Precautionary Covid-19 postings are present at the front door and at the entry point. There is one entry point designated where sign in procedures and screening will occur. The staff are temperature screening visitors upon entry into the facility. LPA is informed that there are currently four (4) Residents in the home.

LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and has a limited supply of Personal Protective Equipment (PPE). LPA discussed the availability of additional PPE supplies to the facility at the time of this visit and advised the facility representatives to contact our office in the event additional supplies are necessary. During this physical plant inspection LPA observed a makeshift bedroom set up in the garage, that included faux walls made of cabinetry and blankets. A bed and personal items were present indicating the area is used as a living/sleeping quarters.

Based on observations made during today’s inspection, there is one (1) deficiency being cited per Title 22, Division 6, of the California Code of Regulations. See LIC 809D This report was reviewed with a copy was provided to the facility representative. Appeal rights were reviewed and provided. A civil penalty accompanies this deficiency.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/20/2022 02:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: SEA BREEZE HOMES OF EASTVALE LLC
FACILITY NUMBER: 331881077

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)

FIRE CLEARANCE: All facilities shall maintain a fire clearance approved by the city, county...

This requirement has not been met as eviidenced by LPA observations of a violation
Deficient Practice Statement
1
2
3
4
Based on LPA observation of a makeshift living/sleeping quarters located in the garage the licensee did not comply with the section cited above. This is a fire clearance violation and which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2022
Plan of Correction
1
2
3
4
Licensee has agreed to cease use of the garage as a sleeping area immediately and provide a written understanding of the regulation section cited and plan for disassembling the makeshift bedroom.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2