306004415-8-9-2023-22-AS-AORZ-CV6SLC-20230829135807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 08/09/2023
Date Signed: 08/09/2023 04:43:50 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
10/13/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221013092710

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: 145	DATE:	08/09/2023
		UNANNOUNCED	TIME BEGAN:	10:51 AM
MET WITH:	Ephantus Warui, Administrator		TIME COMPLETED:	01:48 PM

ALLEGATION(S):

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-Facility neglected resident resulting in wound having maggots

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced visit for the purpose to deliver findings for complaint allegation listed above. LPA Quiroz was greeted and met with Administrator (AD) Ephantus Warui and discussed purpose of today's visit.
During the course of the investigation, LPA Quiroz conducted 10 day visit on 10/18/2022, conducted interviews with interviewees consisting of residents, staff and other witnesses, facility inspection visit of Resident 1( R1s) bedroom area and reviewed the following documents of (R1) but not limited to: Physician Report, identification form, Needs and Services plan, Fountain Valley Hospital Discharge records dated 10/15/2022 and Able Hands Home Health Records.
Regarding the allegation "Facility neglected resident resulting in wound having maggots," the investigation revealed the following: Resident 1 (R1) was admitted to the facility on 01/20/2020 and was admitted to Able Hands Home Health Care on 7/8/2021 requiring services two times per week for wound care then increased to daily care on 9/16/2021 and additional wound care specialist services one time per week.
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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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-20221013092710

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: 08/09/2023

NARRATIVE

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CONTINUED...
During the course of the investigation, LPA Quiroz interviewed five interviewees. Five of Five interviews denied the allegation that "Facility neglected resident resulting in wound having maggots" indicating that Able Hands Home Health care and Wound Specialist were the ones responsible to provide wound care services treatment for (R1) indicating that the facility staff is not permitted to provide wound care. Three of five interviewees indicated that facility staff made sure to keep right lower extremities dry and that facility staff communicated any signs and/or symptoms reported by (R1) to Able Hands Home Health Care.
Therefore based on the preponderance of evidence gathered through interviews conducted with interviewees, observations and documentation review conducted by LPA Quiroz, the allegation that the "Facility neglected resident resulting in wound having maggots" is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint.

No deficiencies cited during today's visit.

An exit interview was conducted with Administrator Ephantus Warui and a copy of report and LIC 811-Confidential Names were 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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC9099 (FAS) - (06/04)

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