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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602472
Report Date: 10/04/2024
Date Signed: 10/04/2024 05:52:59 PM


Document Has Been Signed on 10/04/2024 05:52 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:
10/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Richard Tibi, Assistant AdministratorTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to conduct a required annual inspection and in conjunction initiate this case management visit. LPA Lopez identified herself and was granted entry by Assistant Administrator Richard Tibi. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Assistant Administrator Tibi.

This visit was in response to an Unusual Incident/Injury Report (IR) that was received at the San Diego Regional Office on Wednesday, September 18, 2024. The IR stated that there was an incident that transpired on Saturday, September 14, 2024, with resident #1 (R1) who was transported to the hospital due to becoming weak. The facility notified the resident’s primary care physician (PCP) and their power of attorney (POA).

During today's visit LPA Lopez toured the facility, spoke with staff, and requested and obtained relevant documents pertinent to this incident. LPA Lopez verified R1 was still in the hospital and was to return to the facility within the next two weeks. Staff said that they contacted the POA to notify them of the residents condition and they agreed to contact emergency personnel to have the resident transported to the hospital due to changes in their condition. According to records R1 had gone to the hospital days prior due to refusing meals.

No deficiencies were cited during today’s visit.

An exit interview was conducted with Assistant Administrator Tibi, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided 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: 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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