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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004415
Report Date: 06/23/2024
Date Signed: 06/23/2024 03:17:08 PM


Document Has Been Signed on 06/23/2024 03:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
306004415
ADMINISTRATOR:KAROLINA FILFACILITY TYPE:
740
ADDRESS:9925 LA ALAMEDA AVENUETELEPHONE:
(714) 962-5531
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:0CENSUS: 0DATE:
06/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Karolina Fil (Via Telephone)TIME COMPLETED:
03:14 PM
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 On today's date, LPA Quiroz called Licensee Karolina Fil via telephone to discuss amended report for complaint control #22-AS-20231004143105. The original report dated 6/17/2024 on page 1 of 2 indicating the 10 day visit dated 7/10/2023 was changed reflecting the actual date the 10 day visit was conducted which was 10/6/2023.

An exit interview was conducted with Licensee Karolina Fil via telephone, and it was explained that a copy of amended report for complaint control #22-AS-20231004143105 and today's report was emailed to Licensee Karolina Fil. The report was sent via email and an electronic email read receipt confirms receiving of the report.


SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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