306004415-1-24-2023-22-AS-AORZ-CP9TJ7-20230221134548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 01/24/2023
Date Signed: 01/24/2023 04:21:45 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
09/21/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200921204110

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:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Ephantus Warui, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Lack of staff
-Staff is withholding resident's funds

INVESTIGATION FINDINGS:

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

On today's date, LPA (Licensing Program Analyst) LPA Rosie Quiroz conducted an unannounced visit for the purpose of concluding a complaint investigation regarding the allegations listed above. LPA Quiroz was COVID screened, granted entry, met and discussed the complaint with Administrator(AD) Ephantus Warui. During the course of the investigation LPA Quiroz interviewed nine interviewees consisting of staff, residents and witnesses. During the course of the investigation, LPA Quiroz reviewed the following but not limited to: residents' physician reports, identification forms, residents records of cash and resources, LIC 500 Personnel Report and Resident Roster.
Interviews conducted with eight of nine interviewees concluded that despite the unforseen COVID-19 circumstances causing staff to be off work due to not feeling well and on required isolation as instructed by the Department of Orange County Public Health due COVID-19 precautionary measures; that staff who were able to work were working overtime to cover shifts for those staff who were not able to work. (AD) Warui indicated plans were implemented to continue to improve the quality of hiring additional staff to cover shifts for those employee requiring COVID-19 Precautionary isolation time off. CONTINUED NEXT PAGE...

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: 01/24/2023

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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 22-AS-20200921204110

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: 01/24/2023

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

CONTINUED...
Based upon Interviews conducted with interviewees, documentation review and information obtained during the investigation; the allegation "Lack of staff" is deemed UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.
During the course of the investigation for "Staff is withholding resident's funds," the investigation revealed that Seaside Terrace Retirement Community is the payee for (R1) and that when facility deposited the stimulus check, it was rejected by bank. Licensee Karolina Fil indicated "The bank informed the facility that only the individual identified on the stimulus check had permission to cash or deposit the stimulus check. Upon receiving that notification from the bank, Administrator Ephantus and I provided the resident's Power Of Attorney (POA)with the stimulus check and informed them the reason why the facility was not able to cash the check for the resident. All three checks for those residents identified as Seaside Terrace Retirement Community being their payee had the stamp from the bank where I signed the check for deposit on behalf of seaside but were rejected. I provided R1's (POA) with the original check upon being rejected by the bank with instructions on how to move forward with cashing the stimulus check for the resident and gave the rejected stimulus check to the other two residents who are alert, aware and coherent and were able to walk in and cash the stimulus checks themselves." Interviews conducted with eight of nine interviewees concluded that staff is not withholding resident's funds. Resident 1 (R1) was able to successfully cash the stimulus check after attending the bank in person accompanied by Family on 11/23/2020. The Investigation revealed that Resident 2 and Resident 3 also successfully cashed their own stimulus checks in person.
Based upon Interviews conducted with eight of nine interviewees, documentation review and information obtained during the investigation; the allegation "Staff is withholding resident's funds" 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: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2