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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004415
Report Date: 09/22/2022
Date Signed: 09/22/2022 02:10:30 PM


Document Has Been Signed on 09/22/2022 02:10 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: 139DATE:
09/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Ephantus Warui, AdministratorTIME COMPLETED:
01:16 PM
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced vist for the purpose to conduct a case management-other inspection visit to deliver an amended report for a visit conducted on 8/2/2022 regarding Complaint Control#: 22-AS-20200629114611.

During today’s visit, LPA Quiroz along with (AD) Ephantus Warui conducted a facility tour inspection of facility premises.

LPA Quiroz reviewed amended report with AD Ephantus Warui with original date of 8/2/2022, and addressed any concerns and/or questions regarding the amendment of the report. AD Ephantus Warui did not have any concerns or questions.

An exit interview was conducted with AD Ephantus Warui. LPA Quiroz read today’s report and amended report with AD Warui. A copy of this report along with amended report was provided at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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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