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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 01/28/2025
Date Signed: 01/28/2025 05:27:30 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
01/10/2025 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250110160728
FACILITY NAME:BEACH TERRACE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306005901
ADMINISTRATOR:DENNIS ROBENIOLFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(714) 694-3205
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 45DATE:
01/28/2025
UNANNOUNCEDTIME BEGAN:
03:39 PM
MET WITH:Dennis Robeniol- Executive Director
Edwin Guzman- Memory Care Program Director		TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff does not keep facility clean, safe, and sanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of concluding and delivering the findings into the above allegation. LPA was greeted and granted entry by Medication Technician (MT) Samantha Hernandez and explained the reason for the visit to Executive Director (ED) Dennis Robeniol at 8:45am.

On January 16, 2025, LPA initiated the complaint investigation. During the course of the investigation, LPA interviewed seven staff and five residents and obtained documentation which consists of the Resident/Staff Rosters, Staff Contacts, Personnel Report, Face Sheets, Physician's Reports, and the Needs and Services Plans of residents. LPA also toured and observed the common areas on both levels.

Regarding the allegation, Facility staff does not keep facility clean, safe, and sanitary, it is alleged that the faclity staff are not cleaning the soiled areas in a timely manner...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
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-20250110160728
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: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary... at all times.

This requirement was not met as evidenced by:
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Memory Care Program Director stated that a carpet cleaning schedule and a plan in writing identifying the staff responsible for cleaning urine and feces as well as to submit an inservice with staff discussing their responsbilities and submit the above to LPA via email by POC due date.
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Based on observation and interviews, brown stains were observed and three out of the five residents and three out of the seven staff corroborated that the urine and feces were not cleaned timely at various times which poses a potential health and safety risk to persons 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: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250110160728
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: 01/28/2025
NARRATIVE
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when a resident is urinating and defecating arounnd the common areas of the third floor. During the walk through conducted on January 16th, LPA smelled a strong urine odor and observed brown stains on the carpet of the third level. Interviews revealed four out of the five residents and seven out of the seven staff identifying a resident leaving accidents around the facility. Three out of the five residents expressed that the accidents are cleaned at various times at the latest being 2 hours. Three out of the seven staff corroborated with the allegation stating that the accidents are not cleaned timely.

Based on observation and interviews, the above allegation is deemed substantiated. A deficiency is being cited the on the attached LIC9099-D.

An exit interview was conducted with Memory Care Program Director Edwin Guzman, and a copy of this report including the LIC9099-D and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3