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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440708739
Report Date: 08/16/2024
Date Signed: 08/16/2024 04:02:51 PM


Document Has Been Signed on 08/16/2024 04:02 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:SEAVIEW GUEST HOMEFACILITY NUMBER:
440708739
ADMINISTRATOR:SULLIVAN, CECILIAFACILITY TYPE:
740
ADDRESS:7321 MESA DRIVETELEPHONE:
(831) 685-2428
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY:6CENSUS: 4DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Kim SullivanTIME COMPLETED:
03:26 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Kim Sullivan. LPA observed 2 staff and 4 residents in the facility.

LPA reviewed 2 resident files and 2 staff files. The centrally stored medication forms of 2 resident files were observed inaccurate and not maintained up to date. 2 out of 2 staff files were observed without valid first aid certificate.

LPA toured the facility inside out with HM. License, ADM certificate and Personal rights posters were observed in the facility. Living room, kitchen, dinning room and two restrooms were inspected. 3 resident bedrooms, 2 staff live-in rooms and laundry area were inspected. Two staff live-in rooms was observed in facility. Medication closet was observed locked. Knives closet was observed unlocked, HM locked it immediately. The cleaning product closet under the sink was observed unlocked, HM added a lock before LPA finished the inspection. Room temperature was at 70 degree F, and hot water temperature was at 106 degree F in facility. First Aid box, flash lights and night lights were observed in the facility. The last time the facility conducted the emergency drill is 7/6/2024. Two days perishable food supplies and seven days nonperishable food supplies were observed sufficient.

Fire extinguisher was serviced on 11/27/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways and exit. The detached garage was as storage room. Back patio, and side patios were observed at backyard.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with HM. This report was provided to HM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
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


Document Has Been Signed on 08/16/2024 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: SEAVIEW GUEST HOME
FACILITY NUMBER: 440708739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 2 out of 2 staff files were observed without valid first aid certificate which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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House Manager stated to submitted a plan of correction by the POC due date for staff to obtain the first aid training and certificate.
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the centrally stored medication forms in 2 out of 2 resident files were observed inaccurate and not maintained update to date which poses/posed a potential health, safety risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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House Manager stated to submit a plan of correction by the POC due date to provide staff training to maintain centrally stored medication form accurate and up to date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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