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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:03:07 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
10/29/2024 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241029184225
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: 46DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Executive Director Dennis RobeniolTIME COMPLETED:
03:14 PM
ALLEGATION(S):
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Facility staff failed to provide records.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit upon entry.

Regarding the complaint allegation: Facility staff failed to provide records.

During the investigation it was discovered a document was requested by the responsible party and Power of Attorney (POA) for Resident 1 (R1). During an interview with staff, it was confirmed a record request was made verbally on Monday, October 28, 2024. Staff explained to the individual making the request, they would need to submit a record request in writing.
Document review reveals a request was made via email the same day, and the individual making the request was denied access to the record(s) for R1.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
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-20241029184225
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: 10/30/2024
NARRATIVE
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Based on the evidence gathered through interview 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.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241029184225
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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
87506(c)(1)
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87506 (c)(1) Resident Records
(C) All information and records obtained from or regarding residents shall be confidential.
(1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident’s written consent or that of his designated representative.
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Executive Director (ED) Dennis Robeniol stated he will read and review regulation section 87506 and send LPA Haley a letter of acknowledgement and understanding. ED Robeniol states they will provide and/or make available the requested documents by the close of business October 31, 2024.
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This requirement is not being met as evidenced by:
Facility staff failed to provide requested records to the responsible person for resident 1 (R1). This poses a potential personal rights 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.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3