306004415-1-11-2024-22-AS-AORZ-CZXW3L-20240129155603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 01/11/2024
Date Signed: 01/11/2024 05:20:45 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
08/30/2023 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230830153658

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:	01:05 PM
MET WITH:	Ephantus Warui, Administrator and Karolina Fil "Via telephone"		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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-Staff do not provide adequate care and supervision to prevent resident from falling.
-Staff does not ensure that resident's toileting needs are met.
-Staff does not ensure that resident is adequately fed.

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 allegations 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 Quiroz conducted the 10 day visit on 9/5/2023. During the course of the investigation, LPA Quiroz reviewed documentation but not limited to physician reports, needs and services plans, staff roster, resident roster, and conducted complaint follow up inspection visits on 1/11/2024. LPA Quiroz conducted interviews with interviewees consisting of residents and staff.
Regarding the allegations: "Staff do not provide adequate care and supervision to prevent resident from falling, “Staff does not ensure that resident's toileting needs are met” and “Staff does not ensure that resident is adequately fed," the investigation revealed the following: Six of Nine interviewees indicated that Resident 1 (R1) resides on the first floor in bedroom directly across from the medication room. 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-20230830153658

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...Seven of nine interviewees indicated that staff are vigilant of those residents who appear to require more frequent checks and supervision and elevate concerns to Administrator to be able to designate bedrooms closer to the medication room and Administration area. (AD) Warui indicated "Upon admission, R1 was identified as being a fall risk and due to R1s medical condition and being forgetful I decided to put her right in front of the medication room."
During Facility inspection visit conducted on 9/5/2023 at 9:45am, LPA Quiroz observed R1 residing in bedroom directly across from the medication room. LPA Quiroz observed Caregiver assisting with activities of daily living and repositioning R1. Eight of nine interviewees denied allegation of “Staff does not ensure that resident's toileting needs are met” indicating staff conduct frequent round checks ensuring resident’s overall needs are being met timely.
During facility inspection visit conducted on 9/5/2023 at 11:05am, LPA Quiroz observed visitor in R1’s bedroom area. LPA Quiroz observed visitor visiting with R1 and observed R1 eating chow mein. Interviews conducted with interviewees consisting of six staff indicated that R1 receives visits from church friends twice per day who have been observed by facility staff to spend time with R1 and bring traditional cultural food items enjoyed by R1 such as chow mein and various noodle dishes.
Physician report dated 2/21/2023 page 4 of 6 indicates R1 is able to feed self. Six interviewees consisting of staff indicated “Resident loves to eat chow mein and noodles and it’s nice that R1s church friends visit because R1 enjoys their food. R1 doesn’t really like the facility food even when the facility menu includes noodle dishes.”
Based on the evidence gathered from interviews conducted, facility inspection observations, and documentation review, the allegation of "Staff do not provide adequate care and supervision to prevent resident from falling,” “Staff does not ensure that resident's toileting needs are met,” and “Staff does not ensure that resident is adequately fed” is deemed Unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis; Therefore complaint allegations are 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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