306004415-1-18-2023-22-AS-AORZ-CN9VXM-20230120154945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 01/18/2023
Date Signed: 01/18/2023 01:26:28 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
12/17/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201217155941

FACILITY NAME:	SEASIDE TERRACE RETIREMENT COMMUNITY		FACILITY NUMBER:	306004415
ADMINISTRATOR:	KAROLINA FIL		FACILITY TYPE:	740
ADDRESS:	9925 LA ALAMEDA AVENUE		TELEPHONE:	(714) 962-5531
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	250	CENSUS: 138	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Ephantus Warui		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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-Resident is being illegally evicted from the facility.

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA), LPA Rosie Quiroz made an unannounced visit to the facility for the purpose of delivering findings of the complaint investigation. Upon arrival, LPA Quiroz was greeted by Front desk receptionist, COVID 19 screened and met with Administrator (AD) Ephantus Warui.
The investigation consisted of interviews with three of three interviewes as well as documentation review but not limited to: Identification Form, Physician Report, Statement of Account for Year 2020, Orange County Superior Court Eviction Restoration Notice dated 6/22/2021, Special Incident Report (SIR) dated 6/21/2021, Writ of Execution dated 5/25/2021 and 30 Day Eviction Notice dated 11/11/2020 for Resident 1 (R1).
The investigation revealed (R1) was admitted into Seaside Terrace Retirement Community on 7/05/2019. Documentation revealed (R1) paid timely rent for 3 of 11 months in 2020, and had a balance of $2,741.16 for 8 of 11 months of rent as of 11/1/2020. Three of three interviews indicated "Resident refused to pay and refused all payment arrangements." The Facility issued a 30 day eviction notice on 11/11/2020. (SIR) dated 6/21/2021 indicated resident was transferred to hospital on 6/19/2021 per her own request and never returned back to facility. CONTINUED...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20201217155941

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: 01/18/2023

NARRATIVE

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CONTINUED...

Orange County Sheriff's Department issued an eviction notice on 6/19/2021 and (R1)s Family picked up (R1)s personal belongings same week (R1) requested to transfer to Hospital.
Based upon Interviews conducted with interviewees, documentation review and information obtained during the investigation; the allegation "Resident is being illegally evicted from the facility" is deemed UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint and no deficiencies are being cited. An exit interview was conducted with AD Warui, and copy of this report and LIC 811- Confidential Names were provided to facility at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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