306005901-1-9-2024-22-AS-SSAS-CZZQ8E-20240131105637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 01/09/2024
Date Signed: 01/09/2024 04:54:32 PM

Unsubstantiated

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
10/18/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231018094417

FACILITY NAME:	BEACH TERRACE MEMORY CARE		FACILITY NUMBER:	306005901
ADMINISTRATOR:	ERIC JENSEN		FACILITY TYPE:	740
ADDRESS:	12282 BEACH BOULEVARD		TELEPHONE:	(503) 675-3925
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	120	CENSUS: 48	DATE:	01/09/2024
		UNANNOUNCED	TIME BEGAN:	11:01 AM
MET WITH:	Eric Jensen - Executive Director		TIME COMPLETED:	01:44 PM

ALLEGATION(S):

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A resident was assaulted by another resident due to a lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit.

The complaint investigation consisted of a review of interviews with facility staff, resident family members, witnesses, and document review.

Regarding the allegation: A resident was assaulted by another resident due to a lack of supervision.
0 of 8 individuals were able to provide any evidence to support the allegation. During the investigation it was determined Resident 1 (R1) had multiple encounters with Resident 2 (R2). Multiple staff members confirmed R1 and R2 did have an encounter in the dining room. Document review revealed there were encounters between R1 and R2 on the dates of October 12, 2023, October 14, 2023, and October 17, 2023.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20231018094417

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: 01/09/2024

NARRATIVE

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Staff was present during all the altercations and families of both parties were notified after every incident.

After reviewing incident reports and charting notes for R1 and R2, there’s no evidence to suggest the altercation that took place was a result of staff not being present or a lack of staff.

Based on the information gathered during the investigation through interviews, document review, and observations, the Department is unable to ascertain if the allegation: A resident was assaulted by another resident due to a lack of supervision, occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC9099 (FAS) - (06/04)

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