306004415-1-11-2023-22-AS-AORZ-CN9LEC-20230120074121

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 01/05/2023
Date Signed: 01/11/2023 10:31:22 AM

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
12/29/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20221229170915

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: 136	DATE:	01/05/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Vanny Long and Epi Warui		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff used inappropriate forms of punishment
Staff falsified resident’s documentation
Facility failed to provide adequate food service
Staff failed to treat resident with dignity and respect

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Lyman conducted the initial 10 day complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility by Front Desk Reception Vanny Long and explained the reason for the visit. Administrator Epi Warui arrived during the visit.

During the course of the investigation, LPA toured the facility, interviewed staff, residents and witness as well as reviewed and obtained pertinent documentation such as physician report, facility notes and facility menu. Regarding the allegations that staff used inappropriate forms of punishment, staff falsified resident’s documentation, staff failed to treat resident with dignity and respect and facility failed to provide adequate food service, the investigation revealed the following: On 11/18/2022, Resident 1 (R1) was assessed by resident's Psychiatric Nurse Practitioner (NP) per request of facility staff. R1 had been having increased behaviors, hallucinations, and statements regarding will to live. NP signed the application for a 72 hour evaluation on 11/18/2022 at 1750 PM. Per facility Administrator, R1 was sent out the next day as a bed had become available CONT ON LIC 9099C DATED 01/11/2022.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

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 4

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
12/29/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20221229170915

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:	DATE:	01/05/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:			TIME COMPLETED:	10:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility doesn’t answer phone calls
Insufficient staffing
Staff are sleeping on the NOC shift.
Staff engaged in inappropriate interactions with resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Lyman conducted the initial 10 day complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility by Front Desk Reception Vanny Long and explained the reason for the visit. Administrator Epi Warui arrived during the visit.

During the course of the investigation, LPA toured the facility, interviewed staff, residents and witness as well as reviewed and obtained pertinent documentation such as facility staffing schedule. Regarding the allegations that Facility doesn’t answer phone calls, Insufficient staffing,staff engaged in inappropriate interactions with resident and staff are sleeping on the NOC shift, the investigation revealed the following: Per interviews and staff schedule, the facility staffing levels are as follows- 3-4 caregivers on first shift in assisted living and memory care, 2-3 caregivers on second shift in assisted living and memory care and 1 each on NOC shift. There is 1 med tech per shift except on NOC where a caregiver trained as a med tech dispenses medications as needed. LPA observed noted staffing during visits. Administrator indicated he was advised that a staff member may be sleeping on the NOC shift. He stated he arrived on shift twice unnanounced to observe staff and both times staff were awake and present. CONT ON LIC 9099C DATED 01/11/2023

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20221229170915

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: 01/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Four out of five staff interviewed deny knowledge of anyone sleeping on NOC shift. Facility staff indicate calling R1's family members for updates. Two out of two staff indicate calling the person listed as a responsible party on the ID page and one staff indicated calling another family member listed as a DPOA. Designated DPOA denied being the agent on the paperwork. Staff 1 (S1) indicated a situation where R1 had requested assistance with adjusting the resident's undergarment. S1 states adjusting the undergarment but denies it was of a sexual nature and was done by request of resident as undergarment was twisted. S2 indicates being told by the resident approximately 10 months ago that S1 had showed the resident her breasts. Ten out of twelve witnesses deny any knowledge of sexually inappropriate behavior or verbiage by any staff. Two witnesses were verbally told of inappropriate situations but did not witness any incidents. Due to conflicting information, LPA is unable to confirm allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20221229170915

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: 01/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

at NP's preferred hospital. Witness indicates resident was sent out as punishment, however R1 was admitted for 18 days under a psychiatric hold then transferred to a skilled nursing facility for further treatment. R1 has not returned to the facility to date. Administrator states being informed by social worker that there is no pending discharge date. Administrator states resident moved out 01/10/2022. R1 was currently prescribed four medications for anxiety and depression as well as two medications for Alzheimer's/ Dementia. Physician report dated 02/02/2022 indicates anxiety and hallucinations. LPA toured the facility during the visit and sampled facility temperatures. Temperatures ranged between 70-75 degrees F. Department regulations require rooms to be heated to at least 68 degrees F. Maintenance Director indicates the thermostats are located in hallways and in the office and are locked. Some rooms have the thermostat in the room. The office team has keys to the thermostat as well as Maintenance Supervisor. Each thermostat controls 6-8 rooms and can be adjusted as needed. Residents are offered portable heaters if they are still cold after adjustment and LPA observed portable heaters in resident rooms. LPA toured the kitchen during the visit. LPA observed ample food supply including fresh fruits and vegetables. LPA obtained the facility menu with varied items and residents are free to order off the menu if they wish. Seven out of seven residents interviewed deemed the food to be acceptable. Therefore the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4