306004415-1-19-2024-22-AS-AORZ-D6CM5M-20240618091834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 01/18/2024
Date Signed: 01/19/2024 01:45:30 PM

Unsubstantiated

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
08/26/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220826122653

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:	0	CENSUS: 119	DATE:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Karolina Fil (Attempted via telephone), Ephantus Warui, Former Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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-Facility is restricting visitation for resident
-Facility is restricting phone calls for resident

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 8/31/2022. During the course of the investigation, LPA Quiroz reviewed documentation but not limited to physician reports, needs and services plans, staff roster, resident roster, visitor log, Durable power of attorney for health care dated 6/9/2022, South Coast Global Medical Center discharge summary dated 8/29/2022, complaint follow up inspection visits conducted on 9/12/2023 and 1/18/2024 and interviews with interviewees consisting of residents, staff and other witnesses.
Regarding the allegations: “Facility is restricting visitation for resident,” and “Facility is restricting phone calls for resident,” the investigation revealed the following: Resident 1 (R1) was admitted to the facility on 8/26/2022. CONTINUED ON NEXT LIC 9099-C 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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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-20220826122653

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: 01/18/2024

NARRATIVE

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CONTINUED...The physician report dated 8/12/2022 indicates Dementia diagnose. Four of six interviewees denied the allegations indicating that phone calls were never restricted for (R1) indicating that when staff would transfer and hand the phone to (R1) that (R1) would shake her head and look away. Four of six interviewees indicated that between the dates of 8/21/2022 through 8/29/2022 (R1) presented with shortness of breath symptoms and that due to COVID-19 precautionary measures at the time and recommendations from Orange County Public Health Department and (R1)s power of attorney for health care at the time were to isolate (R1) until medically cleared for health and safety concerns and COVID-19 precautionary measures. The Discharge summary from South Coast Global Medical Center dated 8/29/2022 indicated (R1) was evaluated for shortness of breath and chest portable exam was found to be within normal limits. Four of six interviewees indicated visits for resumed back to normal on 8/29/2022 after medical evaluation clearance.
Seven residents interviewed denied the allegations indicating facility is not restricting visitors and phone calls and were conducting COVID-19 screening due to COVID-19 precautionary measure indicating that if there is a new visitor wanting to visit with the residents or calling to speak to the residents; that facility staff prefer to check in with the residents first as best practice to ensure the residents health and safety.

Therefore based on the preponderance of evidence gathered through interviews conducted with interviewees consisting of staff, residents, witnesses, documentation review and observations conducted by LPA Quiroz, the allegations that the "“Facility is restricting visitation for resident,” and “Facility is restricting phone calls for resident,” are deemed UNSUBSTANTIATED meaning although the allegations may have happened or are valid, however there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. This agency has investigated the complaint. No deficiencies cited during today's visit.

LPA Quiroz attempted to conduct an exit interview with Licensee Karolina Fil via telephone, however no response. LPA Quiroz left detailed voicemail with complaint findings requesting signed copy of report to be submitted to Community Care Licensing by COB Date. A copy of this report along with LIC 811- Confidential Names list were provided to Licensee Karolina Fil via email.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

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