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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600582
Report Date: 10/12/2023
Date Signed: 10/12/2023 05:15:40 PM


Document Has Been Signed on 10/12/2023 05:15 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SEA BREEZE HOME & CARE IIFACILITY NUMBER:
374600582
ADMINISTRATOR:CATHERINE H. COFFMANFACILITY TYPE:
735
ADDRESS:1231 16TH STREETTELEPHONE:
(619) 424-9486
CITY:SAN DIEGOSTATE: CAZIP CODE:
92154
CAPACITY:4CENSUS: 3DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee, Catherine CoffmanTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA identified herself and was granted entry by Ana Kairuz to whom she disclosed the purpose of the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, of which all must be ambulatory. During today’s inspection, there were a total of three (3) in care, of which both were ambulatory. The facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by licensee, toured the interior and exterior of the facility, and inspected the rooms. The facility was clean and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, toilet, and shower were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s internal temperature and refrigerator and freezer temperatures were within regulatory range.

During today’s visit, LPA observed, via measurement with a thermometer, was within regulatory range, at 112 degrees.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. There was plenty of food for clients at the facility. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, accessible to clients. Medications were labeled, as required and stored in locked areas. Confidential records were appropriately stored. No pools or bodies of water were observed on the premises.

Continue at LIC809C
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SEA BREEZE HOME & CARE II
FACILITY NUMBER: 374600582
VISIT DATE: 10/12/2023
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Continue from LIC809

Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and present during the visit and reviewed staff and client records. The three (3) clients were out in the community and not available for an interview. LPA interviews did not raise any licensing concerns. The client files which LPA reviewed contained required documents. Staff records contained proof of current first aid training, as the last training for which certification was maintained was on 10/21/2022 and it expires on 10/21/2024. Licensee presented proof of current/active business liability insurance and current surety bond.

No deficiencies were cited during today's visit. An exit interview was conducted with Licensee, Coffman, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2