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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004415
Report Date: 01/24/2023
Date Signed: 01/24/2023 04:20:19 PM


Document Has Been Signed on 01/24/2023 04:20 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



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: 138DATE:
01/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Ephantus Warui, AdministratorTIME COMPLETED:
10:17 AM
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On today's date, Licensing Program Analyst (LPA)LPA Quiroz was COVID-19 screened, greeted and met with Administrator Ephantus Warui and discussed purpose of today's unannounced visit to conduct a case management-other inspection visit to review documentation for Resident 1 (R1) regarding Complaint Control#: 22-AS-20221103113552.

During today’s visit, LPA Quiroz along with (AD) Ephantus Warui conducted a facility tour inspection of facility premises. LPA Quiroz reviewed documentation for Resident 1 during today's visit.

No deficiencies noted during today's visit. An exit interview was conducted with (AD) Ephantus Warui. A copy of this report along with LIC 811 Confidential names were provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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