374602472-10-4-2024-08-AS-CLOZ-D9R2ZQ-20241004175042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602472
Report Date: 10/04/2024
Date Signed: 10/04/2024 05:51:51 PM

Document Has Been Signed on 10/04/2024 05:51 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: 24	DATE:	10/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Richard Tibi, Assistant Administrator		TIME COMPLETED:	04:00 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 required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Assistant Administrator Richard Tibi. LPA discussed the purpose of the visit with Assistant Administrator Tibi. According to the facility’s license, there may be a maximum of 32 residents all of whom may be non-ambulatory in at any given time at the facility site. The facility is approved seven (7) hospice residents, and four (4) bedridden residents. They also have a waiver for non-physicians to prescribe medications. During today’s inspection, the facility’s current census is 24 residents living at the facility. There were 20 residents present at the facility site during the inspection. LPA, accompanied by Assistant Administrator Tibi, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 74 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were not all compliant: kitchen sink measured hot water at 115.2 degrees F; sink in restroom #1 delivered hot water at 116.4 degrees F; sink in restroom #2 delivered hot water at 116.4 degrees F; sink in restroom #3 delivered hot water at 116.2 degrees F; sink in restroom #4 delivered hot water at 116.4 degrees F; sink in restroom #5 delivered hot water at 115 degrees F; sink in restroom #6 delivered hot water at 113.9 degrees F; sink in restroom #7 delivered hot water at 126 degrees F; sink in restroom #8 delivered hot water at 127.8 degrees F; sink in restroom #9 delivered hot water at 125.8 degrees F; sink in restroom #10 delivered hot water at 124 degrees F; sink in restroom #11 delivered hot water at 123.4 degrees F; sink in restroom #12 delivered hot water at 125.8 degrees F; and sink in restroom #13 delivered hot water at 124.5 degrees F. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

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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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: 10/04/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking, dining equipment and utensils were present, and all safely stored in a locked kitchen area. There were no toxic chemicals or poisons accessible to residents. Medications were properly labeled, as required, and stored in locked cart. LPA inspected the medication cart and confirmed medications were properly labeled and stored.

No pools or bodies of water on the premises. Per Assistant Administrator Tibi, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were present (05) and serviced within the last 12 months. First aid kit was complete and readily accessible.

LPA reviewed staff and resident records. During today’s visit there were 20 residents on the facility premise. LPA's inspection did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

Deficiencies observed and cited during today's annual inspection may be found on the LIC809-D page of this report.

An exit interview was conducted with Assistant Administrator Richard Tibi to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

LPA requested Assistant Administrator Tibi to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, Emergency Disaster Plan LIC 610-E, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2024 05:51 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: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 7 out of 13 water taps exceeded the allotted temperature and had no warning signs which poses a potential safety risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Facility will adjust their water heater temperature to reduce the temperatures at taps and monitor the teperature at the taps. Facility agreed to inform LPA once all their hot waters have been adjusted to have LPA return and measure the hot water by POC due date, 10/18/2024.

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 6 out of 10 resident files did not have an updated Physician's Report (LIC602) which posed a potential personal rights risk to persons in care.
	POC Due Date: 10/25/2024
	Plan of Correction
1 2 3 4	Facility agreed to obtain updated LIC602s, place in the residents file and agreed to send a digital copy to LPA by POC due date, 10/25/2024.

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 Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2024 05:51 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: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(d)

Admisson Agreements

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of10 resident files did not obtain an admission agreement which posed a potential personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Facility agreed to obtain a signed admission agreement in the residents file and submit a digital copy to LPA by POC due date, 10/18/2024.

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: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024

LIC809 (FAS) - (06/04)

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