306004415-6-27-2024-22-AS-AORZ-D6NVE6-20240628162148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 06/17/2024
Date Signed: 06/27/2024 12:46:26 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
10/04/2023 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231004143105

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: 126	DATE:	06/17/2024
		UNANNOUNCED	TIME BEGAN:	02:42 PM
MET WITH:	Ephantus Warui, Former Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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-Staff did not adequately supervise residents, resulting in a resident getting assaulted by another resident while in care.

INVESTIGATION FINDINGS:

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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced complaint visit to deliver findings on the above allegations received on 10/04/2023. LPA Quiroz was greeted and granted entry into the facility by front desk receptionist and met with Administrator Ephantus Warui and explained the purpose for the visit.
LPA Quiroz conducted the 10 day visit on 10/6/2023. During the course of the investigation, LPA Quiroz conducted interviews with interviewees consisting of staff working on various shifts, obtained copies of pertinent documents and conducted observations during facility inspection visit dated 10/6/2023 and 12/20/2023.
Regarding the allegation, “Staff did not adequately supervise residents, resulting in a resident getting assaulted by another resident while in care,” the investigation revealed the following: Resident 1 moved in to the facility on 7/24/2023. Physician report dated 7/24/2023 indicated R1 to have dementia diagnose, with episodes of confusion and non-ambulatory status. Resident 2 (R2) moved into the facility on 1/20/2017.
CONTINUED ON NEXT LIC 9099-C PAGE...***This is amended report***

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: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

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-20231004143105

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: 06/17/2024

NARRATIVE

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CONTINUED...Physician report dated 8/22/2023 for R2 indicated R2 to have dementia diagnose, no confusion/disoriented and non-ambulatory status.
On 9/8/2023, the Orange County Regional Office received a self reported incident report reporting altercation between R1 and R2. The special incident report (SIR) indicated that while Caregiver was doing their room checks on 9/8/2023 at 6:15am, that they observed R2 next to R1 and observed R2 physically attacking R1. SIR indicated Caregiver immediately removed R2 away from R1 vicinity. R1 was observed to have a bruise on head area and some cuts on both hands. SIR indicated Fountain Valley Police Department and Paramedics were called to the facility resulting in R1 being transferred to hospital for assessment and R2 was transferred to Huntington Beach Hospital to rule out Danger to others.
During the course of the investigation, nine of nine interviewees denied the allegation indicating staff would conduct routinely checks on Resident 1 (R1) and Resident 2 (R2). Nine of nine interviewees indicated R1 and R2 were observed to be getting along indicating R2 was observed to be friendly to R1, other residents and staff. Nine of nine interviewees denied any prior history or any altercations between R1 and R2 indicating there was no knowledge before the altercation between R1 and R2 took place.
Therefore, based on the information gathered during the investigation through interviews, observations and documentation review; the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.
An exit interview was conducted with Former Administrator Ephantus Warui. LPA Quiroz attempted to call Licensee Karolina Fil with no response or call back. LPA Quiroz not able to obtain signature from Licensee Karolina Fil during today’s visit.

***This is an amended report***

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC9099 (FAS) - (06/04)

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