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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005901
Report Date: 11/16/2023
Date Signed: 11/16/2023 04:30:00 PM


Document Has Been Signed on 11/16/2023 04:30 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:BEACH TERRACE MEMORY CAREFACILITY NUMBER:
306005901
ADMINISTRATOR:ERIC JENSENFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(503) 675-3925
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 47DATE:
11/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:11 PM
MET WITH:Eric Jensen - Executive Director TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20230306125953.

During the complaint investigation mentioned above, it was discovered Resident 1 (R1) had several falls that were not reported to the department. Hospice document review revealed R1 had several falls between January 2023 – June 2023. The last fall reported to the Department was a fall that took place on December 25, 2022, before R1 was placed on hospice. No other falls were reported to the department. In addition to the facilities failure to report R1’s falls, R1 passed away June 28, 2023 and the death was not reported to the department as required.

As a result of today’s Case Management visit, deficiencies will be cited.

An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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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Document Has Been Signed on 11/16/2023 05:32 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/16/2023 05:22 PM

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: BEACH TERRACE MEMORY CARE
FACILITY NUMBER: 306005901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2023
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) a written report shall be submitted to the licensing agency... within seven days... (D) Any incident which threatens the welfare, safety, or health of any resident, such as... or unexplained absence of any resident.
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Executive Director Eric Jensen will review Regulation Section 87211 (Reporting Requirements) and email a plan of action that will prevent a failure to report in the future. The plan will include who will be responsible for sending incident reports to the Regional Office.
POC due date: November 22, 2023 at 1:00 PM.
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This requirement is not being met as evidenced by the facility failing to report documented falls by Resident 1 and the death of Resident 1 on June 28, 2023. The Region Office did not received any incident reports for the falls during the time period of January 2023 – June 2023, or R1’s death on June 28, 2023.
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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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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