306005495-5-31-2024-22-AS-AJLO-D6CT7C-20240618142831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005495
Report Date: 05/31/2024
Date Signed: 05/31/2024 12:15:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
05/09/2024 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20240509112030

FACILITY NAME:	BEACH HOMES III		FACILITY NUMBER:	306005495
ADMINISTRATOR:	BEACH, ANDY		FACILITY TYPE:	740
ADDRESS:	2336 COLLEGE DR		TELEPHONE:	(714) 549-1905
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 5	DATE:	05/31/2024
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Samantha Chiascione - Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff failed to supervise a resident resulting in an elopement from the facility

INVESTIGATION FINDINGS:

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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Caregiver Elizabeth Serpas. LPA met with Samantha Chiascione, Administrator (AD) and explained the nature of the inspection.

The department received a complaint on 5/9/2024 stating facility staff failed to supervise a resident resulting in an elopement from the facility and that the facility did not adequately report the elopement to the department. The Reporting Party (RP) disclosed that the elopement resulted in local law enforcement being called. During the investigation, the department interviewed Administrator (AD), staff and residents in care.

(continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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 3

Control Number 22-AS-20240509112030

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: BEACH HOMES III	FACILITY NUMBER: 306005495
	VISIT DATE: 05/31/2024

NARRATIVE

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(continued from LIC9099)

On 5/15/2024 LPA conducted a visit to the facility. LPA interviewed Administrator (AD), staff and residents in care. Interviews conducted with AD and staff revealed that S1 observed R1 attempting to depart the facility through the front door. S1 followed R1 out the door attempting to de-escalate R1 as they began to walk away from the facility. AD arrived at facility and joined S1 in attempting to de-escalate R1. AD instructed S1 to return to the facility. AD contacted local law enforcement. AD was able to de-escalate R1 and returned to the facility with R1. According to interviews with AD, staff and Resident 2, Resident 1 was never unsupervised. AD and staff corroborated the allegation that the facility did not adequately report the elopement to the department. LPA interviewed Resident 1 who could not recall the details of the incident in question and made no disclosures regarding the allegations. LPA obtained copies of the following files for Resident 1: Admission Agreement, Pre-Placement Appraisal and Physician's Report. LPA obtained copies of the following staff files: personnel reports, protocol for walking with residents and training records. LPA obtained copies of the client roster, and record of staff working at facility on 3/27/24.

On 5/15/2024 LPA returned to the facility and conducted interviews with AD and Resident in care. AD made no further disclosures regarding the allegation. Resident 3 could not recall the details of the event in question and made no disclosures regarding the allegations.

Due to interviews conducted, LPA was unable to determine if facility staff failed to supervise a resident resulting in an elopement from the facility. Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation. Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and this report was reviewed with Administrator. A copy of this LIC-9099 was provided to the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
05/09/2024 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20240509112030

FACILITY NAME:	BEACH HOMES III		FACILITY NUMBER:	306005495
ADMINISTRATOR:	BEACH, ANDY		FACILITY TYPE:	740
ADDRESS:	2336 COLLEGE DR		TELEPHONE:	(714) 549-1905
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 5	DATE:	05/31/2024
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Samantha Chiascione - Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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9

Facility did not adequately report the elopement to the Department

INVESTIGATION FINDINGS:

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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Caregiver Elizabeth Serpas. LPA met with Samantha Chiascione, Administrator (AD) and explained the nature of the inspection.

During the investigation, there was sufficient evidence to substantiate the allegation of facility did not adequately report the elopement to the department. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. Based on the investigation, LPA determined that the facility did report the incident to local law enforcement and R1 was never left unsupervised. A Technical Violation (TV) for reporting requirements is being issued.

An exit interview was conducted, and this report was reviewed with Administrator. A copy of this LIC-9099 was provided to the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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 3