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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005901
Report Date: 12/13/2022
Date Signed: 12/13/2022 03:15:49 PM


Document Has Been Signed on 12/13/2022 03:15 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:EDWARDS, CYNTHIAFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(503) 675-3925
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 20DATE:
12/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Eric JensenTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit. LPA Haley was greeted, granted entry and explained the reason for today visit. LPA Haley met with Executive Director (ED) Eric Jensen.

The purpose of today's visit was to speak with ED Jensen regarding the staffing, and the importance of having back up staff in place during the flu season.ED Jensen advised LPA Haley staffing has been adequate and Brightstar (Staffing Agency) has been contacted to provide temporary staffing if needed.

ED Jensen will be providing LPA Haley a current LIC500 and a the staff schedule from November 2022, through present. Furthermore, ED Jensen will be providing LPA Haley and list of all residents and staff that have been cleared since testing positive for COVID, and an activities calendar.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report and was provided to ED Eric Jensen.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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