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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604523
Report Date: 05/31/2024
Date Signed: 06/11/2024 12:28:35 PM


Document Has Been Signed on 06/11/2024 12:28 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: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: 5DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Administrator Sonya KarpalTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required- 1 year inspection visit. The LPA introduced himself to and disclosed the purpose of the visit to Administrator Sonya Karpal. The facility was licensed for a capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility also had a hospice waiver for four (4) residents.


The LPA, accompanied by administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, and stored in a locked area.



A pool was observed to be have a perimeter fence and locked. Per staff, no firearms, nor ammunition were kept at the facility. A carbon monoxide detector, emergency lighting, and facility telephone were all working. Fire extinguisher(s) and a first aid kit were readily accessible. Required licensing postings were observed in a visible area of the facility.

Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection.

An exit interview was conducted with Administrator, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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