306004415-6-23-2020-22-AS-AORZ-BRLP6R-20200717110247

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 06/23/2020
Date Signed: 06/23/2020 10:44:06 AM

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
03/02/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200302092422

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:	06/23/2020
		UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Ephantus Warui, Administrator		TIME COMPLETED:	10:27 AM

ALLEGATION(S):

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-Unlawful eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosie Quiroz conducted a tele visit on this day for the purpose of delivering findings regarding complaint control #22-AS-20200302092422. Today’s visit was conducted via tele visit due to COVID-19 precautionary measures.
During the course of this investigation, LPA Quiroz conducted interviews,reviewed documents including but not limited to admission agreement and Notice of 30-day eviction letter that the facility administrator Ephantus Warui issued to the Resident 1 (R1) and Community Care Licensing. On February 26, 2020 Administrator Warui provided (R1) and Assisted Living Waiver (ALW) Coordinator with a writeen Notice of 30-day eviction as required per California Health & Safety code.
During the course of the investigation it was concluded that R1 has been in and out of the hospital due to medical reasons; therefore the ALW payment has not been paid out to the facility due to R1 not being present at the facility in betweeen long periods of time since moving in on 1/1/2020.
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Unsubstantiated

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: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

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
03/02/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200302092422

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:	06/23/2020
		UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Ephantus Warui, Administrator		TIME COMPLETED:	10:27 AM

ALLEGATION(S):

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-Staff did not provide resident with mail in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosie Quiroz conducted a tele visit on this day for the purpose of delivering findings regarding complaint control #22-AS-20200302092422. Today’s visit was conducted via tele visit due to COVID-19 precautionary measures.
During the course of this investigation, LPA Quiroz conducted interviews,reviewed documents including but not limited to admission agreement.
During the course of the investigation it was concluded that Resident 1 (R1) has been in and out of the hospital due to medical reasons which as a result caused on multiple occasions caused R1 to not receive mail documents timely due to not being present in the facility. On 3/12/2020, during a facility case management visit, LPA Quiroz observed United States Postal Service delivering mail to front desk receptionist. Front Desk receptionist sorted mail, and announced "today's mail is ready for pick up at front desk reception area" via intercom immediately after mail was delivered at facility.
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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: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

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-20200302092422

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: 06/23/2020

NARRATIVE

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LPA Quiroz observed mail that was not picked up by residents was properly filed in secured locked drawer in front desk area. Per interviews, it was concluded that if the residents are not present in the facility and out of the facility due to hospitalization or other matters, the Administrator is notified and the mail is filed in secured cabinet area until residents returns to facility and the mail is given during the resident's arrival back to the facility. LPA Quiroz observed all mail is filed properly, and the secured cabinet area were mail is stored was observed to be locked.

This agency has investigated the complaint alleging "Staff did not provide resident with mail in a timely manner." The allegation "Staff did not provide resident with mail in a timely manner" is found to be UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Administrator Ephantus Warui via telephone. The report was sent via email and an electronic email read receipt confirms receiving of the report. Administrator Warui agrees to review the report and to send the signed report back to the LPA Quiroz via email.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200302092422

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: 06/23/2020

NARRATIVE

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It was concluded that due to R1 being away from the hospital, R1 was not submitting Social Security Income (SSI) required documents accordingly to SSI office. which interrupted his SSI Payment. R1 required hospitalization effective 3/14/2020, and currently still residing at a skilled nursing facility and has no set scheduled date to return back to facility at this time.
It is noted that in effort to support R1, the administrator agreed to extend the relocation deadline and will safeguard R1's personal belongings to alleviate R1's stress until further notice.
This agency has investigated the allegation noted above. Therefore, based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegation “unlawful eviction," is deemed to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
An exit interview was conducted with Administrator Ephantus Warui via telephone. The report was sent via email and an electronic email read receipt confirms receiving of the report. Administrator Warui agrees to review the report and to send the signed report back to the LPA Quiroz via email.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

LIC9099 (FAS) - (06/04)

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