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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 12/24/2024
Date Signed: 12/24/2024 02:39:33 PM

Substantiated


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
12/05/2024 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241205102328
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: 45DATE:
12/24/2024
UNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Dennis RobeniolTIME COMPLETED:
11:37 AM
ALLEGATION(S):
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Medication was not administered as prescribed.
INVESTIGATION FINDINGS:
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Regarding the complaint allegation: Staff not administering medication as prescribed.

During the investigation, 5 of 6 facility staff members confirmed the allegation above, and document review revealed information to support the allegation. A review of Resident 1’s (R1) charting notes reveal on November 23, 2024 and December 7, 2024 R1’s family was contacted about refilling R1’s medication. R1’s family was upset because specific instructions were given regarding refilling R1’s medications upon R1’s admission. Staff 4 confirmed R1 has missed medications, and confirmed R1’s family gave specific instructions regarding refilling the residents medications.

Based on the evidence gathered through 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.
An exit interview was conducted and a copy of this report and appeal rights were provided.
Substantiated
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)
Page: 1 of 2
Control Number 22-AS-20241205102328
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/26/2024
Section Cited
ILS
87465(a)(1)
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87465 Incidental Medical & Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Executive Director (ED) Dennis Robeniol stated he will develop a plan on refilling resident medications and review the new plan with the care team. ED Robeniol will also conduct an in-service training on regulation section 87465 for all care staff.
ED Robeniol agrees to email LPA Haley the new procedure for refilling resident medications and a copy of the in-service training sign in sheet. once the training has been completed. The plan for refilling medications should be completed by the POC Due date. The in-service training should be scheduled by 1:00PM on the POC due date.
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This regulation was not met as evidenced by:
On more than one occasion Resident 1’s refills were requested late resulting in R1 missing medications.
This poses a health and safety risk to residents in care.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2