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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 06/10/2024
Date Signed: 06/10/2024 03:02:25 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
06/04/2024 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240604120144
FACILITY NAME:BEACH TERRACE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306005901
ADMINISTRATOR:ERIC JENSENFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(530) 242-8300
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 38DATE:
06/10/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Eric JensenTIME COMPLETED:
01:49 PM
ALLEGATION(S):
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Staff improperly destroyed medication, including narcotics.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit regarding a complaint that was filed June 4, 2024. During the investigation, interviews were conducted, and documents were reviewed.

Regarding the allegation: Staff improperly destroyed medication, including narcotics.

4 of 6 staff interviewed were able provide information on the medication destruction process. According to Staff 2 (S2), Staff 5 (S5), and Staff 6 (S6), medication is destroyed during the NOC (overnight) shift. According to S2, depending on what shift received an order, the medication will be placed in a bin and the NOC shift will destroy the medication. S6 says, they believe medication is being destroyed on the NOC shift because they have more down time. Document review revealed, medication has been destroyed by several different individuals and some medication destruction records did not have any signature on the medication destruction record.
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: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
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-20240604120144
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 ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306005901
VISIT DATE: 06/10/2024
NARRATIVE
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Based on the evidence gathered during interviews, and document 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.

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: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20240604120144
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 ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306005901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2024
Section Cited
CCR
87465(i)(1)(2)(3)(4)
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87465 Incindental Medical and Dental Care
(i) Prescription medications which are not taken...upon termination of services, not returned to the issuing pharmacy... shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:
(1) Name of the resident.
(2) The prescription number and the name of the pharmacy.
(3) The drug name, strength and quantity destroyed.
(4) The date of destruction.
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Executive Director Jensen will conduct an in-service training for all staff on the proper disposal of prescribed medications. ED Jensen will send LPA Haley a detailed outline of the in-service training, and a sign in sheet for all staff who attended the training.
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This requirement is not being met as evidenced by interview confirmation and document review that reveal the Administrator is not present when medication is being destroyed and overnight staff are destroying medication. This poses a health and safety risk to residents in care.
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CCR
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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: Lourdes MontoyaTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
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