306004415-1-16-2024-22-AS-AORZ-D6FT4Z-20240621142427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 01/16/2024
Date Signed: 01/16/2024 04:02:07 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
09/27/2021 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210927085947

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:	01/16/2024
		UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Karolina Fil, Licensee		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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-Resident fell while in care.
-Resident has scabies.
-Staff did not seek medical attention in a timely manner.
-Resident's needs are not being met.
-Food service is inadequate.
-Facility is not communicating with responsible party.
-Facility does not provide activities for residents.

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 former Administrator (AD) Ephantus Warui and discussed purpose of today's visit. LPA Quiroz called Licensee Karolia Fil and left a voicemail detailing purpose of today’s visit.
LPA Quiroz conducted the 10 day visit on 9/28/2021. During the course of the investigation, LPA Quiroz reviewed documentation but not limited to physician reports, needs and services plans, staff roster, resident roster, Medication Administration Records, Special Incident Reports and conducted complaint follow up inspection visits on 9/12/2023. LPA Quiroz conducted interviews with interviewees consisting of residents and staff.
Regarding the allegations: "Resident fell while in care,” “Staff did not seek medical attention in a timely manner” and “Facility is not communicating with responsible party,” the investigation revealed the following: Six of seven interviewees denied the allegations and verified that Resident 1 (R1) resides on the memory care unit. Physician Report dated 5/5/2020 indicated (R1) is ambulatory. CONT ON LIC 9099C 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: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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-20210927085947

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: 01/16/2024

NARRATIVE

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CONTINUED...Administrator (AD) and Medication Technician (MT) indicated that on 9/25/2021, (R1) reported right elbow pain and area was observed to be swollen by (MT). (AD) and (MT) indicated (R1)s responsible party was informed following observation of swelling on (R1) right elbow and obtained approval from responsible party to send (R1) out for evaluation. On 9/25/2021, (R1) was seen by Nurse Practitioner for chief complaint of joint swelling and pain to right elbow for several days and history of gout. Progress notes from 9/25/2021 visit reflect (R1) was alert during time of visit and denied history of injuries or trauma to right elbow. Progress noted concluded swelling present on 9/25/2021 and no deformity, effusion or lacerations present.
Regarding the allegations: “Resident’s needs are not being met” and “Facility does not provide activities for residents, the investigation revealed the following: Eight of nine interviewees consisting of residents and staff denied the allegations indicating that although facility experienced staffing challenges due to COVID-19, that staff was working hard to meet the resident’s needs. (AD) Warui indicated “I was even working late every day to make sure all of the resident’s needs were being met and I was covering for staff who was out sick with COVID-19.” Eight of nine interviewees indicated that Group activities were not being permitted due to COVID-19 cases and precautionary measures as recommended by Orange County Public Health during that time indicating that Activity Coordinator and caregivers were splitting their time daily to conduct 1:1 activities with residents daily as time permitted.
Regarding the allegation “Resident has scabies,” the investigation revealed the following: Six of seven interviewees denied the allegation indicating (R1) presented with a rash and was seen virtually by (R1)s primary care physician. Six of seven interviewees indicated “But the rash was never a confirmed scabies episode and was treated for dermal rash.” Medication Administration Records review for (R1) indicate (R1) was treated with Ketoconazole 2% cream with order start date of 6/10/2021 and end date of 12/7/2021.
Regarding the allegation “Food service is inadequate,” the investigation revealed the following: Fourteen of fifteen interviewees denied the allegation indicating that the facility menu has a variety of food and that residents receive three meals a day and snacks. Residents interviewed indicated that when residents do not like food item being served that a substitute food choice is offered and readily available. Fourteen of fifteen interviewees reported that resident’s food was being delivered to the resident’s bedroom during dining-room closure due COVID-19 precautionary measures orders from the Orange County Public Department. During inspection visits conducted in person on 9/12/2023 and 1/16/2024, LPA Quiroz inspected the kitchen and dining room area. LPA observed the facility had 2-day perishable and 7-day non-perishable food readily available for residents in care.
CONTINUED ON NEXT LIC 9099-C PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210927085947

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: 01/16/2024

NARRATIVE

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Based on the evidence gathered from interviews conducted, facility inspection observations, and documentation review, the allegations of "-Resident fell while in care,” “Resident has scabies,” “Staff did not seek medical attention in a timely manner,” “Resident's needs are not being met,” “Food service is inadequate,” “Facility is not communicating with responsible party,” and “Facility does not provide activities for residents” are 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. LPA Quiroz called Licensee Fil and left detailed voicemail requesting signed copy of report to be submitted 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: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC9099 (FAS) - (06/04)

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