306005901-10-9-2024-22-AS-LMOA-DAFAUG-20241027003155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:04:57 PM

Unfounded

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
11/28/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231128104857

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: 42	DATE:	10/09/2024
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Alysia Noriega		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility admitted resident without legal consent.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to complete and close the investigation regarding the complaint allegation above. LPA was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of interviews and document review.

Regarding the complaint allegation: Facility admitted resident without legal consent.

During the investigation document review revealed Resident 1’s (R1) admission agreement was signed and dated on June 9, 2023 by R1’s Power of Attorney (POA). A review of the signed California General Durable Power of Attorney agreement was signed by R1 and R1's POA on May 6, 2023. The agreement states the following: TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF (N) AND IGNORE THE LINES IN FRONT OF THE OTHER POWERS.

Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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-20231128104857

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 MEMORY CARE	FACILITY NUMBER: 306005901
	VISIT DATE: 10/09/2024

NARRATIVE

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R1 initialed the line in front of (N) and ignored all the other lines in front of the other powers. Line in stated the following: (N) ALL OF THE POWERS LISTED ABOVE. R1 signed and dated the California General Durable Power of Attorney agreement on May 6, 2023. The agreement was signed by the POA, validated by a notary public and stamped twice with the notary’s name and commission number.

Based on the information gathered during the investigation through interview and document review, the following allegation: Facility admitted resident without legal consent, is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis.

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

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

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