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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604523
Report Date: 05/11/2022
Date Signed: 05/11/2022 12:06:28 PM


Document Has Been Signed on 05/11/2022 12:06 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:SEA BREEZE SENIOR LIVINGFACILITY NUMBER:
374604523
ADMINISTRATOR:LEBODA, MARIEFACILITY TYPE:
740
ADDRESS:5403 AVENIDA FIESTATELEPHONE:
(619) 277-8868
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 6DATE:
05/11/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Licensee, Vinod Karpal, and Staff, Sonya Karpal and Lauren Lowney.TIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Sabel Martinez, conducted a scheduled Pre-Licensing inspection to observe the physical plant for compliance, and conduct a Component III. The LPA was greeted by Licensee, Vinod Karpal, Staff Sonya Karpal, and Lauren Lowney, to whom the purpose of the visit was disclosed to. The facility is in a change of ownership process. The San Diego Fire Department inspection was completed on 03/16/2022. The facility is approved for a total capacity of six (6) residents, with one (1) resident being bedridden.

An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care, including in the area of infection control practices. The LPA observed locked centrally stored medications for residents; Perishable and nonperishable food requirements, Available personal storage space for residents, Available leisure activity space for residents; Knives/sharp objects and cleaning supplies were secured and inaccessible to residents; Indoor and outdoor passageways were free from obstructions, and a pool/body of water was observed to be secured and inaccessible to residents.

The following infection control practices were observed; One central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; Signs throughout the facility to promote hand hygiene; face coverings worn by staff and residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of Personal Protective Equipment (PPE) . The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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 BREEZE SENIOR LIVING
FACILITY NUMBER: 374604523
VISIT DATE: 05/11/2022
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The Pre-licensing and Component III were completed on today's date. The Facility is ready to be licensed pending management approval. This is a change of ownership application and there are currently six (6) residents in care. An exit interview was conducted with Licensee, Vinod Karpal, Staff Sonya Karpal and Lauren Lowney. A copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) were provided to the Licensee, Vinod Karpal.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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