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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 12/13/2023
Date Signed: 12/13/2023 04:14:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/28/2022 and conducted by Evaluator Jerome Haley
COMPLAINT CONTROL NUMBER: 22-AS-20221228161711
FACILITY NAME:BEACH TERRACE MEMORY CAREFACILITY NUMBER:
306005901
ADMINISTRATOR:EDWARDS, CYNTHIAFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(503) 675-3925
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 47DATE:
12/13/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Eric Jensen - Executive Director TIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff did not provide resident with a comfortable bed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegation above. LPA Haley was granted entry and explained the reason for the visit with upon entry. During the visit LPA Haley conducted interviews with four residents, and 1 additional staff member Staff 5 (S5) to gather additional information.

Regarding the allegations: Staff did not provide resident with a comfortable bed

During the investigation it was discovered a resident was observed laying directly on the springs of his bed. LPA Haley was provided a photo of the resident laying directly on the bed frame with no mattress or sheets. There was a blue blanket laying on top of the resident and that was the only linen observed in the photo. In the photo you could see the resident’s mattress propped up against the wall. It is unclear why the resident was laying on the bed frame without a mattress or linen. An individual provided the photo on January 19, 2023 at 4:30 PM. The individual did not provide an exact time the picture was taken, but said
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
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-20221228161711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/13/2023
NARRATIVE
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it was in taken in the morning. When the individual observed the resident laying on the bedframe with no mattress, they asked a Med Tech/caregiver why the resident laying on the bed frame and the Med Tech was unaware the resident was not laying on their mattress and did not know why the resident’s mattress was off the bedframe leaning against the wall. The photo taken of the resident laying on the bedframe was compared to a photo taken from inside of a room at Beach Terrace Memory Care, it is clear the photo provided on January 19, 2023 was taken from inside a resident room at Beach Terrace Memory Care.

Based on the evidence gathered during the investigation and photo review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An exit interview was conducted and a copy of this report 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: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221228161711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Executive Director Eric Jensen agrees to review regulation section 87468.1 Personal Rights of Residents in All Facilities with all staff. Executive Director Jensen will send a signed statement of understanding along with a sign in sheet for all staff trained on the regulation section mentioned above. POC due date is December 21, 2023 at 1:00PM
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This requirement is not being met as evidenced by a photo of Resident 1 laying on a bedframe with no mattress that was forwarded to LPA Haley on January 19, 2023 at 4:30PM. The mattress can be seen in the same photo propped up against the wall. This poses a health and safety 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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3