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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004415
Report Date: 08/15/2023
Date Signed: 08/15/2023 10:06:00 AM


Document Has Been Signed on 08/15/2023 10:06 AM - 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: 146DATE:
08/15/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Vanny Long, Ephantus WaruiTIME COMPLETED:
10:20 AM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on two self-reported incident reports received in the Orange County Regional Office (OCRO) on 08/10/23. LPA met with Staff Vanny Long and explained the purpose of the inspection. Administrator (AD) Ephantus Warui arrived during the inspection.

During the inspection, LPA and AD toured the facility. LPA observed there were approximately 20 staff and 135 residents present. LPA conducted health and safety checks on 5 of the 6 residents involved in the incident, as 1 resident is in the hospital, and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed the electricity and water were running, the medications were properly stored, and the facility had soap and paper towels. LPA requested and reviewed copies of the resident roster, staff roster, resident files, and staff files. LPA reviewed documentation regarding the timeliness of the facility’s report of the incident.

Facility representative was advised that at this time further investigation is required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
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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