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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602472
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:00:24 PM


Document Has Been Signed on 07/22/2024 03:00 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 LIVINGFACILITY NUMBER:
374602472
ADMINISTRATOR:ANNE OWENS STONEFACILITY TYPE:
740
ADDRESS:740 SEVENTH STREETTELEPHONE:
(619) 429-0633
CITY:IMPERIAL BEACHSTATE: CAZIP CODE:
91932
CAPACITY:32CENSUS: 24DATE:
07/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Jay Agustine, Executive DirectorTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to deliver findings for complaint investigation and in conjunction conduct this case management visit. LPA identified herself and was granted entry by Sharon Hays, Activities Coordinator. LPA met with Executive Director Jay Agustine and discussed the purpose of today’s visit.

During the complaint investigation, control # 08-AS-20240418105131, the following was discovered: on 04/18/2024, the San Diego Regional Office (SDRO) received an incident report (IR) for resident #1 (R1). The IR reported that on 04/15/2024 R1 was found on the floor at 9:00 AM. According to the report staff immediately initiated 911 where paramedics transported R1 to the hospital. Upon further review of facility records, the charting notes state that R1 had fallen twice on 4/15/2024 and emergency response was initiated two (2) hours after the initial fall due to staff being unable to speak with R1. According to the IR, R1 was confused, pale and very weak.

Based on the evidence obtained during the complaint investigation, deficiencies were observed and being cited during today’s case management and may be reviewed on the LIC809-D page of this report.

An exit interview was conducted, a plan of correction was jointly developed with Executive Director Jay Agustine. A copy of this report, LIC811 and the Licensee Rights (01/2016) were provided to Executive Director Agustine at the conclusion of the visit. The signature below serves as confirmation of receipt of these documents.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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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Document Has Been Signed on 07/22/2024 03:00 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: SUN AND SEA ASSISTED LIVING
FACILITY NUMBER: 374602472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2024
Section Cited
CCR
87465(g)

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87465 Incidental Medical and Dental:
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Executive Director will update the SIR and conduct staff in-service training on RELIAS for Reporting Incidents for documenting special incident reports properly and submit in-service training sheet and certificates for med techs and ED to LPA via email, by POC due date of 08/05/2024.
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Based on records review the facility did not contact emergency personnel immediately after the initial fall and waited two hours to contact resident to be transported to the hospital which posed a potential health risk for 1 of 25 residents (R1) 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: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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