306004415-4-1-2021-22-AS-AORZ-BZWVV8-20210409164550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 04/01/2021
Date Signed: 04/01/2021 04:00:01 PM

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
04/07/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200407135242

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:	ZIP CODE:	92708
CAPACITY:	250	CENSUS: 137	DATE:	04/01/2021
		UNANNOUNCED	TIME BEGAN:	02:42 PM
MET WITH:	Ephantus Warui, Administrator		TIME COMPLETED:	03:11 PM

ALLEGATION(S):

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Carpets in hallways and resident's rooms are stained and dirty.

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz contacted Administrator Ephantus Warui for the purpose to deliver findings for a complaint investigation via telephone due to COVID-19 and pre-cautionary measures.
The initial 10-day visit was completed on 4/09/2020. During the initial 10 day tele visit, LPA Quiroz toured the facility along wtih Administrator Ephantus Warui virtually due to COVID-19 Precautionary measures.
During the course of this investigation, LPA Quiroz conducted interviews, reviewed documents including but not limited to carpet removal and floor installation price quote proposals dated 2/20/2020 and 3/11/2020.
It was alleged that "Carpets in hallways and resident's rooms are stained and dirty." During the course of this investigation, LPA Quiroz conducted multiple interviews with interviewees, reviewed price quote proposals documents and communication with contractors provided by facility; and conducted observations of carpet during virtual tele visit conducted on 4/9/2020. 8 of 8 interviewees corroborated with the allegation. However, 6 of 8 interviewees reported having knowledge of facility inquiring price quote proposals for removal of carpet and floor installation. CONTINUED ON NEXT PAGE...

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: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

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-20200407135242

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: 04/01/2021

NARRATIVE

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Documentation reviewed with dates of 2/20/2020 and 3/11/2020 included price quote proposals with 3 different companies inquiring about carpet removal and floor installation prior to complaint initial date of 4/7/2020.

Based on a review of the documentation, observations and interviews conducted, we have found the complaint allegation of "Carpets in hallways and resident's rooms are stained and dirty," is deemed UNSUBSTANTIATED; meaning 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.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

LIC9099 (FAS) - (06/04)

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