306005901-12-12-2024-22-AS-MSTC-DCC3XU-20241226173856

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 12/12/2024
Date Signed: 12/12/2024 04:45:57 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
09/09/2024 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240909112643

FACILITY NAME:	BEACH TERRACE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	306005901
ADMINISTRATOR:	ERIC JENSEN		FACILITY TYPE:	740
ADDRESS:	12282 BEACH BOULEVARD		TELEPHONE:	(530) 242-8300
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	120	CENSUS: 45	DATE:	12/12/2024
		UNANNOUNCED	TIME BEGAN:	07:40 AM
MET WITH:	Dennis Robeniol		TIME COMPLETED:	01:59 PM

ALLEGATION(S):

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Staff not administering medication as prescribed
Facility staff provided falsified documents

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of, interviews with facility staff, a resident, document review, and observation.

Regarding the complaint allegation: Staff not administering medication as prescribed.

During the investigation, 5 of 6 individuals acknowledged and/or confirmed resident medications have not been administered as prescribed. According to a staff member that was interviewed, med techs were pulled from the med cart for medication administration errors. During an interview with Staff 2, the staff member stated, I did have to pull one of them off the med cart and I was going to pull another one, but they resigned. They were combining 5:00pm and 8:00pm meds.
Continued on LIC9099C

Substantiated

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: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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-20240909112643

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: 12/12/2024

NARRATIVE

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The complaint allegation was confirmed by Staff 3 (S3), Staff 4 (S4), and Staff 5 (S5). According to S3, Staff members have been let got as a result of medication errors. S4 and S5 both revealed 6:00am medications have been missed for two of the residents.

During an interview with Resident 1 (R1), the resident confirmed not receiving medication on two different dates. R1 had detailed notes, and knew what medications were missed. Photos were taken of R1’s notes.

Regarding the complaint allegation: Facility staff provided falsified documents

During the investigation, 4 of 5 staff members provided information the supports the complaint allegation. According to S2, it was discovered med techs are asked to go back and fill out the Medication Administration Record (MAR) for medications already administered. S4 and S5 both confirmed they have been asked to go back and initial the MAR for medication that were already administered. During an interview with S3, it was discovered the MAR has been filled out after medication have been administered. S3 stated, we will bring it to them and give them a verbal and if it continues, we write them up.

Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegations are 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 Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240909112643

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: 12/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/16/2024 Section Cited CCR 87468.2	1 2 3 4 5 6 7	(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: This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director (ED) Robinel will develop a detailed plan for staff to document all medications administered to residents in real time. In the detailed plan, ED Robinel will explain what measures will be taken so med techs will have enough time to complete the MAR in real time as medications are administered. ED Robinel will email LPA Haley the detailed plan of action by 10:00am on the POC Due date.
	8 9 10 11 12 13 14	Facility staff failed to administer medications as prescribed on more than one occasion for more than one resident. This poses a health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 12/16/2024 Section Cited CCR 87207	1 2 3 4 5 6 7	87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Executive Director Robinel will have all staff read and review the regulation section 87207 False Claims. All carestaff are required to sign a statement of understanding, acknowledging the regulation section was read and understood. ED Robinel will provided the signed statements to LPA Haley by 10:00am on the POC due date.
	8 9 10 11 12 13 14	Facility staff provided incomplete records with inaccurate information. Multiple staff were asked to go back and initial the Medication Administration Records (MAR) for medications previously administered and/or missed medications.	8 9 10 11 12 13 14

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 Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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