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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604444
Report Date: 11/22/2021
Date Signed: 11/22/2021 05:15:44 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:
11/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Applicant Bong Lai "Lucie" LeTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to Applicant Bong Lai "Lucie" Le.

The facility fire clearance was granted on July 12th, 2021 and reflects that the facility is approved for 6 residents, of which 2 can be non-ambulatory.

During today’s visit, LPA accompanied by Le, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 77 degrees F. Water temperature at resident faucets were in compliance: Kitchen sink was 112.3 F, Bathroom #1 sink was 113.5 F, Bathroom #2 sink was 116.4 F, Bathroom #3 sink was 115 F, and Bathroom #4 sink was 113.4 F.

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future resident use. Refrigerator temperature was 37 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential resident and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility. [CONTINUED ON LIC 809-C]
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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: 11/22/2021
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[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Two fire extinguishers and one first aid kit were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6, Chapter 8 of California Code of Regulations and Health & Safety Code. The applicant also completed Component III Training. The applicant passed the pre-licensing inspection. Le was advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicant, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.

SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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