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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004415
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:09:53 PM


Document Has Been Signed on 04/19/2022 02:09 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:250CENSUS: 130DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Assistant Adminstrator Vanny Long & Administrator Epi WaruiTIME COMPLETED:
11:04 AM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting an annual visit. LPA was greeted and granted entry into the facility by Vanny Long and explained the reason for the visit. Administrator Epi Warui was present as well with an administrator's certificate that expires on 06/09/2023. Facility is a two story building with capacity for 250 residents.

At 9:08 AM, LPA toured the facility with Administrator Assistant Vanny Long , Facility has 130 residents in care during today's visit. LPA observed residents relaxing outside or in their rooms. At 9:24AM Administrator Epi Warui arrived, the rest of the tour was conducted with Administrator. LPA spoke with various residents who expressed satisfaction with the facility.Facility appears clean and sanitary. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet as well as temperature taking. Facility takes resident and staff temperatures daily and documents. LPA observed screening documents. Facility has covid precaution postings. LPA observed multiple sanitizing stations throughout the facility. Resident rooms have all the required elements. LPA observed ample emergency food and water as well as first aid kit. LPA observed a shaded outside area for smoking and a visitation area . Fire extinguishers are mounted and charged and located throughout the facility. Facility has an ample supply of PPE, incontinence, and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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