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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 08/02/2022
Date Signed: 09/22/2022 01:27:01 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/29/2020 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20200629114611
FACILITY NAME:SEASIDE TERRACE RETIREMENT COMMUNITYFACILITY NUMBER:
306004415
ADMINISTRATOR:KAROLINA FILFACILITY TYPE:
740
ADDRESS:9925 LA ALAMEDA AVENUETELEPHONE:
(714) 962-5531
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:250CENSUS: 139DATE:
08/02/2022
UNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Ephantus Warui, AdministratorTIME COMPLETED:
02:34 PM
ALLEGATION(S):
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-Lack of supervision resulting in a resident assaulting another resident while in care
INVESTIGATION FINDINGS:
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to the facility to deliver findings on the above complaint investigation. LPA Quiroz was COVID-19 screened and granted entry by Front Desk Receptionist. LPA Quiroz met with Administrator (AD) Ephantus Warui, and discussed the purpose of today's visit to deliver findings for allegation listed above.
LPA Quiroz conducted the 10 day visits on July 1, 2020 via telephone due to COVID-19 and pre-cautionary measures. During the course of the investigation, LPA Quiroz conducted interviews with interviewees and reviewed the following records for Resident (R1): Physician Report, Needs and Services Plan, and Fountain Valley Police Department Incident call Report dated 6/26/2020.
During the course of the investigation, five of five Interviewees interviewed, including R1, denied the allegation of "lack of supervision resulting in a resident assaulting another resident while in care" as Resident 2 (R2) was no longer R1’s roommate. The investigation revealed, R1 resided alone at the time of incident due to new roommate being hospitalized. ***THIS IS AN AMENDED REPORT***
CONTINUED ON NEXT PAGE...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20200629114611
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SEASIDE TERRACE RETIREMENT COMMUNITY
FACILITY NUMBER: 306004415
VISIT DATE: 08/02/2022
NARRATIVE
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CONTINUED...

Therefore, R1 did not share a room with another resident. Five of five interviewees including R1 denied ever witnessing residents wander into R1’s room. On 6/26/2020 when alleged resident on resident assault occurred, R1 refused to speak with Fountain Valley Police Department. During the incident R2 was found to be asleep in their own bedroom.

Based on the evidence gathered from interviews and a review of pertinent documentation, allegation of "Lack of supervision resulting in a resident assaulting another resident while in care" is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Therefore complaint is dismissed.

An exit interview was conducted, and a copy of this report, LIC 811- Confidential Names list was provided to Administrator Ephantus Warui at exit.

****THIS IS AN AMENDED REPORT***
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2