Inspection Reports for
Sea Bluffs
25411 Sea Bluffs Dr., Dana Point, CA 92629, Dana Point, CA, 92629
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Inspection Report — Dec 19, 2025
Plan of Correction State
Date: Dec 19, 2025
Visit Reason
Licensing Program Analyst Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon deficiencies cited on 2025-11-07.
Findings
All previously cited deficiencies under Title 22 Regulations 87464(f)(1), 87204(a), and 87203 have been cleared. The licensee provided proof of correction and complied with the terms of the POC.
Citations (3)
Title 22 Regulation 87464(f)(1) pertaining to Basic Services deficiency has been cleared with proof of correction.
Title 22 Regulation 87204(a) pertaining to Limitations deficiency has been cleared with proof of correction.
Title 22 Regulation 87203 pertaining to Fire Safety deficiency has been cleared with proof of correction.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Broadhurst | Administrator/Director | Facility administrator met during the inspection. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the Plan of Correction visit. |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report — Dec 19, 2025
Complaint Investigation State
Date: Dec 19, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff allowed the Durable Power of Attorney (DPOA) to dictate visitors for residents, potentially restricting visitation rights.
Complaint Details
The complaint alleging that staff allowed the POA to dictate visitors for residents was substantiated based on interviews, document review, and observations. The facility was cited for violating residents' visitation rights.
Findings
The investigation substantiated that staff restricted visitation for Residents 1 and 2 by requiring DPOA approval, contrary to regulations. The facility failed to ensure residents were allowed visitation, posing a potential health and safety risk.
Citations (1)
CCR 87468.1(a)(11): Residents in residential care facilities shall have the right to have visitors, including ombudspersons, visit privately during reasonable hours without prior notice. This requirement was not met as staff restricted visitation to DPOA approval only for Residents 1 and 2.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Brent Broadhurst | Administrator | Facility administrator present during the investigation |
Inspection Report — Nov 7, 2025
Complaint Investigation State
Date: Nov 7, 2025
Visit Reason
The visit was an unannounced case management inspection triggered by an unusual incident report involving a resident who left the Memory Care unit unassisted and was found outside the facility.
Complaint Details
The visit was complaint-related due to an unusual incident report of a resident elopement. The resident diagnosed with dementia was not allowed to leave unassisted. The complaint was substantiated by the findings.
Findings
The inspection found that a resident with dementia was able to leave the Memory Care unit unassisted and was found approximately 0.5 miles away from the facility. Staff did not respond to delayed egress exit gate alarms during the visit, resulting in deficiencies cited under Title 22 Division 6 of California Code of Regulations.
Citations (1)
CCR 87464(f)(1) Basic services were not met as Resident 1 was able to leave Memory Care and was found approximately 0.5 miles away from the facility. This poses an immediate health and safety risk to persons in care.
Report Facts
Civil Penalty: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Haley Gmach | Assistant Executive Director | Met with during the inspection. |
| Andrea Mendivil | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection. |
| Brent Broadhurst | Administrator/Director | Facility administrator named in the report header. |
Inspection Report — Nov 7, 2025
Annual Inspection State
Date: Nov 7, 2025
Visit Reason
The visit was an unannounced annual required inspection to evaluate compliance with licensing requirements for The Sea Bluffs facility.
Findings
The facility was generally clean, safe, and sanitary with adequate supplies and emergency preparedness. However, two Type A deficiencies were cited related to residents housed in rooms not approved for bedridden status and a delayed egress exit door chained from the outside, posing immediate health and safety risks.
Citations (2)
CCR 87204(a) - Two residents who are bedridden were housed in rooms not approved for bedridden status, posing an immediate health, safety, or personal rights risk.
CCR 87203 - The delayed egress exit door was chained from the outside, preventing resident access to the patio and lacking approved fire clearance, posing an immediate health, safety, or personal rights risk.
Report Facts
Residents on hospice care: 9
Residents bedridden allowed: 10
Water temperature range: 107
Water temperature range: 116.4
Last smoke detector test date: Oct 16, 2025
Last fire inspection date: Oct 31, 2025
Last emergency drill date: Sep 24, 2024
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Broadhurst | Administrator | Named as facility administrator and involved in inspection tour. |
| Haley Gmach | Assistant Executive Director | Joined inspection tour and met with LPAs. |
| Kenia Cabada | Business Office Manager | Participated in facility tour during inspection. |
| Kimberly Lyman | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Andrea Mendivil | Licensing Program Analyst | Conducted the inspection. |
Inspection Report — Aug 26, 2025
Follow-Up State
Date: Aug 26, 2025
Visit Reason
The visit was a follow-up case management inspection to review an incident report regarding the death of a resident reported on August 25, 2025.
Findings
The Licensing Program Analyst toured the facility and reviewed the resident's file. No immediate health and safety concerns were observed and no deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent Broadhurst | Administrator/Director | Met with during the inspection visit. |
| Fred Arias | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Alisa Ortiz | Licensing Program Manager | Named in the report header. |
Inspection Report — Mar 18, 2025
Complaint Investigation State
Date: Mar 18, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of staff inappropriately touching a resident, handling a resident in a rough manner, and making inappropriate comments towards a resident.
Complaint Details
The complaint investigation was unsubstantiated. Interviews with 8 of 9 individuals denied the allegations. The resident and family expressed no concerns. The department was unable to ascertain if the allegations occurred as reported.
Findings
The investigation included interviews with staff, residents, and a witness, as well as document review. Most individuals denied the allegations, and the family of the resident had no concerns. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation |
| Brent Broadhurst | Executive Director | Facility administrator met during the investigation |
| Haley Gmach | Assistant Executive Director | Facility staff met during the investigation |
Inspection Report — Jan 27, 2025
Complaint Investigation State
Date: Jan 27, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff accepted money from a resident.
Complaint Details
The complaint allegation that staff accepted money from a resident was substantiated based on interviews and evidence gathered during the investigation.
Findings
The investigation substantiated the allegation that a staff member accepted a monetary gift of $1000 from a resident, which violates company policy. Deficiencies were observed related to residents' personal rights under Title 22 Division 6 Chapter 8 of the California Code of Regulations.
Citations (1)
CCR 87468.1(a)(3) requires residents to be free from punishment, humiliation, intimidation, abuse, or punitive actions such as withholding money. Staff accepted a monetary gift from a resident, presenting a potential health, safety, and personal rights risk.
Report Facts
Monetary Gift Amount: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Brent Broadhurst | Administrator | Facility administrator present during the investigation |
| Armando J Lucero | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report — Dec 23, 2024
Annual Inspection State
Date: Dec 23, 2024
Visit Reason
Licensing Program Analysts conducted an unannounced required annual visit to evaluate the facility's compliance with regulations.
Findings
Two deficiencies were cited related to unsecured toxins in a kitchen cabinet and expired food items found in the assisted living area kitchen. Both deficiencies were corrected during the visit.
Citations (2)
CCR 87309(a)(1) Storage Space: The cabinet below the kitchen sink in memory care used to store toxins was not locked and secured, posing an immediate health and safety risk.
CCR 87555(b)(8) General Food Service Requirements: Perishable food such as milk, salad dressing, beef, and fish were expired, and pork patties were found at room temperature on a kitchen counter, posing an immediate health and safety risk.
Report Facts
Deficiencies cited: 2
Hospice residents: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pedro Ucros | Maintenance Director | Mentioned in relation to facility tour and cabinet door replacement |
| Haley Gmach | Assistant Administrator | Met with Licensing Program Analysts and provided documentation |
| Fred Arias | Licensing Program Analyst | Conducted inspection and authored report |
| Andrea Mendivil | Licensing Program Analyst | Conducted inspection |
| Alisa Ortiz | Licensing Program Manager | Supervisor and named in report |
Inspection Report — Sep 24, 2024
Complaint Investigation State
Date: Sep 24, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility was falsifying resident records.
Complaint Details
The complaint alleging falsification of resident records was substantiated based on interviews and record review. Staff S1 was incorrectly identified as an LVN on facility forms, which was confirmed to be false.
Findings
The investigation substantiated the allegation that the facility falsified resident records by indicating a staff member as a licensed vocational nurse (LVN) when they were not licensed. This posed a potential health and safety risk to residents.
Citations (1)
CCR 87207: Licensee failed to ensure no false or misleading statements were disseminated. Facility form letter states staff S1 is an LVN when the staff is not licensed, posing a potential health and safety risk to residents.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Luther | Administrator | Facility administrator present during the investigation |
Inspection Report — Nov 3, 2023
Original Licensing State
Date: Nov 3, 2023
Visit Reason
The inspection was conducted as a pre-licensing visit for a change of ownership and to evaluate readiness for licensing as a Residential Care Facility for the Elderly (RCFE).
Findings
The facility was found to be compliant with all observed requirements including resident apartment furnishings, medication storage, fire safety equipment, and plumbing. The licensing analyst determined the facility is ready for licensing.
Report Facts
Non-ambulatory Residents: 78
Bedridden Residents: 10
Fire Extinguisher Service Date: Oct 16, 2023
Smoke Detector Service Date: Oct 16, 2023
Fire Clearance Date: Aug 8, 2023
Hot Water Temperature Range: 105-120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dwayne Mason Jr | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Andrea Luther | Assistant Executive Director | Facility representative met during inspection |
| Jill Libhart | Regional Director of Operations | Facility representative met during inspection |
| Jenifer Larsen | Regional Director of Health Services | Facility representative met during inspection |
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