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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005901
Report Date: 11/27/2024
Date Signed: 11/27/2024 11:12:01 AM

Document Has Been Signed on 11/27/2024 11:12 AM - 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 ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306005901
ADMINISTRATOR/
DIRECTOR:		ERIC JENSENFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(530) 242-8300
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY: 120TOTAL ENROLLED CHILDREN: 0CENSUS: 46DATE:
11/27/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Dennis RobeniolTIME VISIT/
INSPECTION COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection for deficiencies cited during Complaint Investigation conducted on November 14, 2024, into Complaint #22-AS-20241112141855. LPA met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection.

Deficiency 87303(a) was cited due to the facility not having an operational call signal system in memory care. During today’s visit, ED confirmed call system continues to be inoperable. Deficiency 1569(c) was cited due to residents being unable to alert staff for assistance from their specific living units. During today’s visit, ED stated residents continue to be unable to alert staff for assistance from their specific living units.

Based on observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.Civil penalties for failure to correct are also being assessed An exit interview was conducted and a copy of this report and appeal rights was left at the facility.

Armando J LuceroTELEPHONE: (714) 703-2840
Claudia GutierrezTELEPHONE: 714-703-2840
DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/27/2024 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents...

This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 11/28/2024
Plan of Correction
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ED stated an alternative call system will replace inoperable pull cord system in memory care and proof provided to LPA via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Armando J LuceroTELEPHONE: (714) 703-2840
Claudia GutierrezTELEPHONE: 714-703-2840

DATE: 11/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2024

LIC809 (FAS) - (06/04)
Page: 2 of 2