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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602472
Report Date: 08/05/2024
Date Signed: 08/05/2024 03:45:30 PM


Document Has Been Signed on 08/05/2024 03:45 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: 25DATE:
08/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Jay Agustine, Executive DirectorTIME COMPLETED:
03:55 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), Carmen Lopez, conducted an unannounced visit to initiate a case management visit. LPA Lopez identified herself and was granted entry by Sharon Hays, Activities Coordinator. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Jay Agustin.

This visit was in response an Unusual Incident/Injury Report (UIR) that was received at the San Diego Regional Office on Thursday, August 1, 2024. Per the UIR the incident transpired on Tuesday, July 30, 2024, with resident #1 (R1) who eloped from the facility.

During today's visit LPA Lopez spoke with staff and resident, and requested and obtained relevant documents pertinent to this incident. According to staff, the resident was last seen on the facility premise at around 11:40 AM prior to their mealtime which was between 12:00 PM and 12:15 PM. According to Executive Director, he last observed resident to be at the facility at around 11:40 AM prior to his departure. About 30 minutes later, he was contacted by the family who made him aware that the resident had eloped and was with law enforcement. Resident was returned to the facility the same day with no injuries. R1's Needs and Service Plan was discussed and updated with the family.

Per the Executive Director, R1 recently moved-in on July 29, 2024. The Executive Director mentioned that staff conduct visual resident head counts during all mealtimes – three times and monitor during incontinence checks– at least about twice and/or on an as needed basis.

Records confirmed that the resident’s move-in date was recent. The incontinence sheets, for 7/30/24, show R1 incontinence time was left blank along with four additional residents for the time frame in question, but per ED it was due to residents not needing incontinence assistance during that time frame. Residents Physician’s Report confirms that the resident is an elopement risk. In review of the residents file, the resident did not have an elopement plan in place. Per the residents Needs and Service Plan, the elopement risk was implemented into R1’s plan on 7/31/24.
(Continuation on LIC809-C)
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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 3


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: 08/05/2024
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
26
27
28
29
30
31
32
(Continuation of LIC809)

According to the Executive Director, as of 7/30/24, the facility implemented a meal check sheet for residents to be accounted for during their mealtimes and in-between times. The facility did conduct in-service training to all staff for elopement. A copy of the forms and training sheets were provided to LPA during the visit.

Based in the information obtained during the visit, there is a deficiency being cited during today’s visit that may be found on the LIC809-D page of this report.

An exit interview was conducted with Executive Director Jay Agustin, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided to Executive Director Agustin, at the conclusion of the visit. The signature below confirms that the documents were received.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/05/2024 03:45 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: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
HSC
1569.317

1
2
3
4
5
6
7
H&S 1569.317 Absentee notification plan for missing residents - Every residential care facility for the elderly, as defined in Section 1569.2, shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan as part of the written record of the care the resident will receive in the facility, as described in Section 1569.80. This requirement was not met as evidency by:
1
2
3
4
5
6
7
Executive Director will implement an elopement plan for R1, and have staff complete Relias training and submit a copy of R1s elopment plan and the staff certificates to LPA via email by POC due date, 8/20/24.
8
9
10
11
12
13
14
Based on records review, the licensee did not provide an elopement plan to meet resident’s needs to R1, 1 of 23 residents in care, which posed a potential safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3