374602472-11-7-2023-08-AS-AROS-CXD366-20231107165748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602472
Report Date: 11/07/2023
Date Signed: 11/07/2023 05:01:24 PM

Document Has Been Signed on 11/07/2023 05:01 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	SUN AND SEA ASSISTED LIVING		FACILITY NUMBER:	374602472
ADMINISTRATOR:	ANNE OWENS STONE		FACILITY TYPE:	740
ADDRESS:	740 SEVENTH STREET		TELEPHONE:	(619) 429-0633
CITY:	IMPERIAL BEACH	STATE: CA	ZIP CODE:	91932
CAPACITY:	32	CENSUS:	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:21 AM
MET WITH:	Executive Director, J. Mhel B. Agustin		TIME COMPLETED:	01:35 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 Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility by Med Tech, Chelsea Eutsey, after identifying themselves and stating the purpose of the inspection. This facility serves thirty two (32) residents 60 and above; all of whom may be non-ambulatory. Hospice care waiver approved for seven (7). Facility approved for four (4) bedridden residents. Waiver approved for non-physicians to prescribe medications.. LPA was accompanied by the Med Tech, Chelsea Eutsey during a tour of the facility. Later Executive Director, J. Mhel B. Agustin joined us. A tour of the facility was conducted which included a sample of resident units, the dining area, recreation rooms, and food storage areas. Signal systems are in place and operational. The last disaster drill was conducted in October 2023. PPE supplies are onsite. No bodies of water are on premises. Passageways were free from obstructions. According to Executive Director, Agustin, there are no weapons and/or ammunition stored on the premises. All doors were operational. Each resident had clean and sufficient bed linens. All extra linens, towels, and washcloths are stored in laundry room. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars however, there is 2 common shower rooms, and the individual bathtubs are not used for bathing. Hot water temperature in residents’ bathrooms were compliant. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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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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: SUN AND SEA ASSISTED LIVING	FACILITY NUMBER: 374602472
	VISIT DATE: 11/07/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Chemicals and cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked on medication cart. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

Staff records review verified that all staff records are complete and compliant except for first aide and first aid/cpr certificates. All staff training were complaint. Resident records reviewed and confirmed compliant. Administrator’s certification is current. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted, this report was discussed with Executive Director, Agustin. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Executive Director, Agustin.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Amy Rodgers	TELEPHONE: 619-997-4108
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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