306005901-12-24-2024-22-AS-LMOA-DDG3M7-20250131172153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 12/24/2024
Date Signed: 12/24/2024 01:53:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
06/24/2024 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240624142605

FACILITY NAME:	BEACH TERRACE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	306005901
ADMINISTRATOR:	ERIC JENSEN		FACILITY TYPE:	740
ADDRESS:	12282 BEACH BOULEVARD		TELEPHONE:	(530) 242-8300
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	120	CENSUS: 45	DATE:	12/24/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Dennis Robeniol - Executive Director		TIME COMPLETED:	09:59 AM

ALLEGATION(S):

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Facility staff handled resident in a rough manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley arrived unannounced for the purpose of concluding the investigation and delivering the findings into the above allegation. LPA explained the reason for the visit to Executive Director (ED) Dennis Robeniol.

During the course of the investigation conducted by LPA Sean Haddad on July 1, 2024, and on December 18, 2024, by LPA Jessica Cho, two resident and five staff interviews were obtained as well as the following pertinent documentation: Resident/Staff Roster, Staff Schedule, Written Statements, Resident’s Face Sheets, Physician’s Report, and Charting Notes.
The investigation revealed the following:

Regarding the allegation, Facility staff handled resident in a rough manner, it was alleged that on June 21, 2023, on or approximately 11:45pm, Resident #1 (R1) was “pulled and yanked” by their arm in an attempt to take R1 back to the second floor.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024

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-20240624142605

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BEACH TERRACE ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 306005901
	VISIT DATE: 12/24/2024

NARRATIVE

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Two out of the two residents did not corroborate the allegation indicating that they were not touched or grabbed inappropriately by staff. Five out of the five staff also denied the allegation indicating that the staff did not engage inappropriately with other residents including R1. Two out of the two staff that were involved in the incident indicated in their written statements that R1 displayed unwanted behaviors due to their medical condition on the evening of June 21st. The two staff indicated that R1 was guided towards the elevator and was supported using their arm to prevent R1 from falling.

Based on the review of R1’s Physician’s Report dated August 16, 2023, the behaviors described in the interviews are consistent with the diagnosis documented on the medical report. Prior to the incident, R1 displayed exit seeking behaviors as well as yelling, being combative/aggressive, and showing fear of being kidnapped per charting notes dated March 22, 2024, and March 26, 2024.

However, the investigation found conflicting statements, therefore, based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility staff handled resident in a rough manner is deemed UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Dennis Robeniol, and a copy of this report was provided.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024

LIC9099 (FAS) - (06/04)

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