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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004415
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:27:18 PM


Document Has Been Signed on 09/07/2022 03:27 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: 141DATE:
09/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ephantus Warui, AdministratorTIME COMPLETED:
03:35 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a Case Management- Deficiencies visit after conducting a Complaint 10 day for Complaint Control #: 22-AS-20220906160601.
On or about 11:19am, while LPA Rosie Quiroz was conducting a facility inspection tour in Room #245 along with Administrator Ephantus Warui, (LPA) Rosie Quiroz and AD Warui detected a smoke odor inside room #245. (AD) Warui asked Resident 1 (R1) "Are you smoking in the room." R1 replied "Yes, I'm sorry it won't happen again." While LPA Rosie Quiroz inspected room #245 for the purpose of investigation complaint control #22-AS-20220906160601, LPA Rosie Quiroz observed an ignited cigarette inside the bathroom area and observed R1 in use of oxygen. This was verified with AD Warui.

LPA Quiroz inquired about ignited cigarette area and provided consultation on oxygen use and Title 22, California Code Of Regulation 87618: Oxygen Administration-Gas and Liquid with R1 and Administrator Warui.


Today's observation is a violation of Title 22, Division 6, of California Code of Regulation 87618(b)(3)(C):
(b)In addition to Section 87611(b), the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment meets the following requirements:(C)Smoking shall be prohibited where oxygen is in use. The facility is being cited and immediate civil penalty LIC 421IM assessed at this time.


Today's report was reviewed with Administrator Ephantus Warui, and a copy of this report, LIC 809-D, LIC 811- Confidential name, Appeal Rights and LIC 421IM Civil Penalty were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/07/2022 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2022
Section Cited

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87618(b)(3)(C):Oxygen Administration - Gas and Liquid.(b)In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements:
(C) Smoking shall be prohibited where oxygen is in use. This requirement was not met as evidenced by: CONTINUED BELOW
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On or about 11:19am, while LPA Rosie Quiroz was conducting a facility inspection tour in Room #245 along with AD Warui, (LPA)Quiroz and AD Warui detected a smoke odor inside room #245. (AD) Warui asked Resident 1 (R1) "Are you smoking in the room." R1 replied "Yes, I'm sorry it won't happen again."
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 While LPA Rosie Quiroz inspected room #245, LPA Rosie Quiroz observed an ignited cigarette inside the bathroom area and observed R1 in use of oxygen. This was verified with AD Warui. This poses an immediate risk to residents in care.

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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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