306004415-2-22-2023-22-AS-AORZ-CPCLXW-20230224080922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 11/07/2022
Date Signed: 02/22/2023 04:31:17 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
11/03/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221103113552

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: 139	DATE:	11/07/2022
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Ephantus Warui, Administrator		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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-Staff refused entry of resident’s medical personnel resulting in resident not receiving prescribed medical attention.

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a 10 day visit to address the allegation listed above. LPA Quiroz was greeted, COVID-19 screened and granted entry into the facility by Administrative Assistant and met with Administrator (AD) Ephantus Warui.
During today's vist, LPA Quiroz along with (AD) Warui conducted a tour of interior and exterior of facility premises and conducted interviews, reviewed documents for Resident 1 including but not limited to: Resident roster, Identification and Emergency Form, Needs and Services Plan, Physician Report and physical therapy order dated 11/4/2022 with fax cover sheet dated at 11/4/2022 at 4:34pm.
It was alleged that "Staff refused entry of resident’s medical personnel resulting in resident not receiving prescribed medical attention." During the course of this investigation, LPA Quiroz reviewed the above mentioned documents requested for review and interviewed interviewees. On 11/03/2022 it was reported a visiting physical therapist from Ethics Home Health Agency arrived and requested to meet with Resident 1(R1).
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: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

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-20221103113552

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: 11/07/2022

NARRATIVE

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CONTINUED...However, interviews conducted with R1’s responsible party and facility staff confirmed that R1 was previously receiving home health services from Grace Home Health Agency and no written notice of change in services had been received by the facility. As a result, it was reported the facility Administrator requested the Ethics Home Health visitor to wait while the change in services could be verified with R1’s physician. The facility later received the written order for the change in Home Health services on 11/04/2022 around 8PM at night. Four of four interviewees did not corroborate with allegation. Four of four interviewees indicated wanting to verify medical personnel for Resident 1 prior to allowing medical personnel entrance intro the facility due to Resident 1s previous Home Health Agency approval was with Grace Home Health Agency.

This agency has found the complaint allegation of "Staff refused entry of resident’s medical personnel resulting in resident not receiving prescribed medical attention," is deemed UNFOUNDED; meaning that the allegation was false, could not have happened or is without a reasonable basis. We have therefore dismissed the complaint allegation listed above.

An exit interview was conducted with Administrator Ephantus Warui and a copy of this report was provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC9099 (FAS) - (06/04)

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