306004415-9-6-2023-22-AS-AORZ-CVNV6W-20230914161014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 09/06/2023
Date Signed: 09/06/2023 04:29:44 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
07/20/2021 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210720171422

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: 142	DATE:	09/06/2023
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Ephantus Warui, Administrator		TIME COMPLETED:	04:28 PM

ALLEGATION(S):

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-Staff inappropriately touched resident.
-Staff made an inappropriate comment towards resident.

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to the facility to deliver findings on the complaint allegations listed above. LPA Quiroz was greeted and granted entry by front desk receptionist. LPA Quiroz met with Administrator (AD) Ephantus Warui, and discussed the purpose of today's visit.
LPA Jenifer Tirre conducted the 10 day visits on July 30, 2021. During the course of the investigation, LPA Quiroz conducted interviews with interviewees consisting of staff and residents, and reviewed the following records for Resident (R1), but not limited to:Physician Report, Needs and Services Plan, identification form, Admission Agreement and Application for up to 72 hour assessment, evaluation and crisis intervention or placement for evaluation and treatment dated July 16, 2021.
Regarding the allegation, "Staff inappropriately touched resident," the investigation revelaed the following: Seven of eight interviewees denied the allegation indicating staff are appropriate towards residents in care. CONTINUED ON LIC 9099-C 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: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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-20210720171422

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: 09/06/2023

NARRATIVE

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CONTINUED...Seven of eight interviewees indicated Resident 1 (R1) was often observed to be agitated and responding to internal stimuli as evidenced by talking to himself when observed to be alone.
Regarding the allegation,"Staff made an inappropriate comment towards resident," Seven of eight interviewees denied the allegation indicating staff are professional and treat residents with dignity and respect. Seven of eight interviewees indicated (R1) often observed to be inappropriate verbally to other residents and staff for no apparent reason.
Based on the evidence gathered through interviews, observations and a review of pertinent documentation conducted by LPA Quiroz, the allegations of "Staff inappropriately touched resident," and "Staff made an inappropriate comment towards resident" are deemed Unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Therefore complaint is dismissed.

An exit interview was conducted with (AD) Ephantus Warui, and a copy of this report, LIC 811- Confidential Names list 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: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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