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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604444
Report Date: 10/06/2021
Date Signed: 11/03/2021 02:20:46 PM

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 RESIDENTIALFACILITY NUMBER:
374604444
ADMINISTRATOR:LE,BONG LAI (LUCIE)FACILITY TYPE:
740
ADDRESS:5711 BOUNTY STREETTELEPHONE:
(619) 916-6114
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:6CENSUS: 0DATE:
10/06/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Bong Lai (Lucie) Le, LicenseeTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Laarni Santiago conducted a follow-up announced Pre-Licensing inspection at the facility. The initial Pre-Licensing visit was conducted on August 25, 2021. LPA Santiago identified herself to Applicant, Bong Lai Le and explained the purpose of the visit was to ensure Title 22 compliance for the initial licensure. The facility plans to serve six (6) elderly residents ages 60 and above. On July 12, 2021, the applicant was granted a Fire Clearance for the facility to serve one (1) non-ambulatory and (5) ambulatory residents.

LPA Santiago observed the areas of correction to include; water temperature was corrected and measured between 109 - 115 degrees F in bathrooms #1 through #4 and kitchen sink, a working telephone land line was observed and available for resident use, a secured locked cabinet in the garage for poisons and hazardous items was observed, personal rights, theft policy posted along with complaint poster was posted on the wall. Lastly, hygiene products were observed and ready for use. However, resident bedrooms are currently occupied by tenants belongings and are not ready for resident use, all residents rooms shall be available for inspection during the next prelicensing visit.

Items reviewed during the visit were in compliance with Title 22, Division 6, Chapter 8, of California Code of Regulations with an exception of the rooms currently being occupied by tenants. Component III was completed during today's visit. The Applicant was advised that the application is pending management final review and approval. A copy of this report and Appeal 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 JacobTELEPHONE: (619) 318-5974
LICENSING EVALUATOR NAME: Laarni SantiagoTELEPHONE: (619) 318-5974
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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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