374604444-8-26-2021-08-AS-LSAO-C68QX4-20210825123255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604444
Report Date: 08/25/2021
Date Signed: 08/26/2021 06:48:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	SEA DRAGON FOUNDATION INDEPENDENT RESIDENTIAL		FACILITY NUMBER:	374604444
ADMINISTRATOR:	LE,BONG LAI (LUCIE)		FACILITY TYPE:	740
ADDRESS:	5711 BOUNTY STREET		TELEPHONE:	(619) 916-6114
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92120
CAPACITY:	6	CENSUS: 0	DATE:	08/25/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Bong Lai (Lucie) Le, Licensee		TIME COMPLETED:	11:35 AM

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) Laarni Santiago conducted an announced Pre-Licensing inspection. LPA identified herself to Applicant, Bong Lai (Lucie) Le, and explained the purpose of the visit which was to evaluate Title 22 compliance for the initial application of initial licensure. The facility plans to serve six (6) residents ages 60 and over. On July 12, 2021, the applicant was granted a Fire Clearance for the facility to serve one (1) non-ambulatory and (5) ambulatory residents. An inspection of the facility was conducted inside and out. The facility has six (6) resident rooms and four (4) bathroom for resident use. Resident bathroom is equipped with a toilet, hand washing and bathing facilities which are sanitary and in operating condition. A grab bar and a non-slip mat were observed in the shower. Water temperature was inspected to be between 80 - 150 degrees F. All lighting fixtures and facility windows were operable and in good condition. Linens supplies were observed and sufficient. Indoor passageways were free from obstructions. Fire extinguisher, smoke and carbon monoxide detectors were present and operational. LPA observed no pools or other bodies of water on the premises. The applicant will not be storing a firearm and ammunition in the property. Facility records will be stored in a cabinet and made confidential. LPA observed facility accommodations including food service, dishes and food storage were observed as well as a first aid kit. Activities and sufficient space in which to conduct activities were present. Applicant’s Administrator Certification is current through April 5th, 2022. Items reviewed during the visit were not in compliance with Title 22, Division 6, Chapter 8, of California Code of Regulations at this time. Therefore, another Pre-Licensing visit and Component III will be required and scheduled once applicant notifies LPA that all areas noted as non-compliant are addressed. This is to ensure compliance with the following: Hot water temperature to be measured between 105 to 120 degrees F., resident bedrooms

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SEA DRAGON FOUNDATION INDEPENDENT RESIDENTIAL	FACILITY NUMBER: 374604444
	VISIT DATE: 08/25/2021

NARRATIVE

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cleared of current tenants belongings and ready for resident use, all residents rooms shall be available for inspection, hygiene supplies available, poisons and cleaning products will be secured and inaccessible, personal rights, theft policy posted along with complaint poster, a facility telephone landline available for use and a current liability insurance.

An exit interview was conducted with Applicant, Lucie Le. A copy of this report along with the licensee Appeal Rights (LIC 9058 01/16) was provided via email. An electronic email read receipt confirms the documents were received. A copy of this report and Applicant Rights (LIC 9058) were provided to the Applicant via electronic mail. An electronic mail read receipt confirmation was requested to be sent to LPA upon receipt of the documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni Santiago	TELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC809 (FAS) - (06/04)

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