306004415-1-11-2024-22-AS-AORZ-CZYSFM-20240130125033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 01/11/2024
Date Signed: 01/11/2024 05:19:01 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
01/03/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220103120452

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: 120	DATE:	01/11/2024
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Ephantus Warui, Administrator and Karolina Fil "Via telephone"		TIME COMPLETED:	12:33 PM

ALLEGATION(S):

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-Resident did not receive adequate care and supervision at the facility.

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 by Front Desk Receptionist and met with Administrator (AD) Ephantus Warui and discussed purpose of today's visit. LPA Quiroz called and spoke to Licensee Karolia Fil and discussed purpose of today's visit via telephone.
LPA Alejandre conducted the 10 day visit on 1/13/2022. During the course of the investigation, LPA Quiroz reviewed documentation but not limited to physician reports, needs and services plans, staff roster, resident roster, Special Incident Report dated 12/28/2021 and conducted complaint follow up inspection visits on 11/16/2023 and 1/11/2024. LPA Quiroz conducted interviews with interviewees consisting of residents and staff.
Regarding the allegation: "Resident did not receive adequate care and supervision at the facility," the investigation revealed the following: Seven of seven interviewees indicated residents in care receive adequate care and supervision at the facility. CONTINUED ON 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: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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-20220103120452

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: 01/11/2024

NARRATIVE

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CONTINUED...Five of seven interviewees indicated that the pandemic caused short staffing due to mandated isolation orders and personal leave time off indicating, "But staff was still conducting routinely checks on the residents and supervising all the residents frequently." Five of seven interviewees indicated that staff are vigilant of those residents who appear to require more frequent checks and supervison and elevate concerns to Administrator to be able to designate bedrooms closer to the medication room and Administration area. (AD) Warui indicated "When staff bring that to my attention, I move them closer to the medication room or the lobby area to be able to closely supervise and provide adequate care to those residents requiring more supervision." During facility inspection visit conducted on 11/16/2023, LPA Quiroz observed R1s bedroom to be located in close proximity to the medication room and lobby area on the first floor.
A special incident report was received in the Orange County Regional Office on 12/31/2021 dated 12/28/2021 indicating that on 12/28/2021 at 2:00pm, R1 called the front desk to report that R1 had fallen while trying to get up. Facility indicated following all immediate actions by assessing resident, conducting reports to all pertinent parties and transferring R1 to Emergency Room for further evaluation.
Based on the evidence gathered from interviews, facility inspection observations, and documentation review, the allegation of "Resident did not receive adequate care and supervision at the facility" is deemed Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis; Therefore complaint is dismissed.
An exit interview was conducted with Licensee Karolina Fil via telephone and a copy of this report along with LIC 811- Confidential Names list were provided to Licensee Fil via email. Licensee Fil agreed to sign copy of report and submit copy with signature back to Community Care Licensing by COB Date.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC9099 (FAS) - (06/04)

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