306004415-5-23-2025-22-AS-MSEY-DGXQCU-20250523120342

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004415
Report Date: 05/23/2025
Date Signed: 05/23/2025 09:20:43 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
09/05/2023 and conducted by Evaluator Cassandra Mikkelson

COMPLAINT CONTROL NUMBER: 22-AS-20230905131105

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: 0	DATE:	05/23/2025
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Karolina Fil		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

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Resident sustained pressure injury while in care

INVESTIGATION FINDINGS:

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On 05/23/2025, Licensing Program Analyst (LPA) Cassandra Mikkelson contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 09/05/2023.

Resident sustained pressure injury while in care
Records reviewed indicated that Resident R1 was being treated by Home health services for a pressure injury while in care. Interview with Home Health Nurse indicated that Home health was providing wound care for R1 due to stage three pressure injury. Documents reviewed indicated that R1 had a pressure injury that was being treated by home health and labeled as a stage three pressure ulcer. Based on interviews conducted and records reviewed, the allegation is substantiated.

Licensee was advised a copy of this report will be sent via certified mail. Appeal rights provided. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 709-6317
LICENSING EVALUATOR NAME: Cassandra Mikkelson	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 22-AS-20230905131105

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEASIDE TERRACE RETIREMENT COMMUNITY	FACILITY NUMBER: 306004415
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/24/2025 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	Resident sustained pressure injury while in care 87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. THis poses an immediate health and safety risk to residents in care.	1 2 3 4 5 6 7	Unable to obtain POC due to facility closure.
	8 9 10 11 12 13 14	This was not met as evidenced by: Resident R1 had a pressure 3 injury while in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 709-6317
LICENSING EVALUATOR NAME: Cassandra Mikkelson	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
09/05/2023 and conducted by Evaluator Cassandra Mikkelson

COMPLAINT CONTROL NUMBER: 22-AS-20230905131105

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: 0	DATE:	05/23/2025
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Karolina Fil		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

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Resident sustained serious injury while in care resulting in hospitalization
Staff did not report an incident to resident’s authorized representative
Resident has lost severe weight while in care
Staff did not meet resident’s hygiene needs
Staff did not notify responsible party of resident's change in condition

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 709-6317
LICENSING EVALUATOR NAME: Cassandra Mikkelson	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20230905131105

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEASIDE TERRACE RETIREMENT COMMUNITY	FACILITY NUMBER: 306004415
	VISIT DATE: 05/23/2025

NARRATIVE

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Resident sustained serious injury while in care resulting in hospitalization

Interviews with staff indicated that Resident R1 was considered a fall risk and preventions were put in to place in order to prevent falls. R1 was residing in a room that was near the medication room so the staff could check on R1 frequently. R1 wore a call button and understood how to use it if help was needed. R1 had begun physical therapy once a week in order to help R1’s strength and mobility. Records indicate that R1 fallen at the facility and staff assisted R1 in a timely manner. R1 was seen at the hospital for evaluation where no serious injuries were observed. Interviews conducted and records reviewed indicated that the allegation that resident sustained serious injury while in care is unsubstantiated.

Staff did not report an incident to resident’s authorized representative

Interviews with staff indicated that they are in contact with R1’s Responsible Party (RP). Staff ensure that if R1 has any changes or an incident occurs, the RP is notified. Records reviewed indicated that R1’s RP was notified when an incident occurred. Based on interviews conducted and documents reviewed, the allegation is unsubstantiated.

Resident has lost severe weight while in care

Interview with Administrator indicated that Resident R1 was not a “good eater” and was picky about the food provided. Administrator stated that R1 had lost weight due to not eating so R1’s physician prescribed Ensure to help get nutrition. Records indicate that R1 was receiving prescribed protein drink Ensure to help get nutrition. Based on interviews conducted and documents reviewed, the allegation is unsubstantiated.

**Report continued on 9099-C2 page**

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 709-6317
LICENSING EVALUATOR NAME: Cassandra Mikkelson	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20230905131105

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEASIDE TERRACE RETIREMENT COMMUNITY	FACILITY NUMBER: 306004415
	VISIT DATE: 05/23/2025

NARRATIVE

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Staff did not meet resident’s hygiene needs

Interview conducted with Administrator indicated that R1 was receiving showers two times weekly. Interview with R1 indicated that they receive hygiene assistance and diaper changing but could not remember when. Interview with RP indicated that R1 refuses showers so there are times where R1 will go an extended period of time without a shower or proper hygiene care. Based on interviews conducted and records reviewed, the allegation is unsubstantiated.

Staff did not notify responsible party of resident's change in condition

Interviews conducted with staff indicated that R1’s Responsible Party (RP) was notified when incidents occurred at the facility. Documents reviewed indicated that R1’s RP was notified when R1 had any incidents at the facility. Based on interviews conducted and documents reviewed, the allegation is unsubstantiated.

Licensee was advised a copy of this report will be sent via certified mail. Two copies of this report will be sent. The Licensee is to sign and return a copy to the Orange County Regional office.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 709-6317
LICENSING EVALUATOR NAME: Cassandra Mikkelson	TELEPHONE: (916) 709-6830
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5