306005901-5-1-2023-22-AS-SSAS-CRHMXN-20230504100011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 04/18/2023
Date Signed: 05/01/2023 09:51:58 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/09/2022 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221109162534

FACILITY NAME:	BEACH TERRACE MEMORY CARE		FACILITY NUMBER:	306005901
ADMINISTRATOR:	EDWARDS, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	12282 BEACH BOULEVARD		TELEPHONE:	(503) 675-3925
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	120	CENSUS: 38	DATE:	04/18/2023
		UNANNOUNCED	TIME BEGAN:	03:16 PM
MET WITH:	Executive Director Eric Jensen		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Facility failed to address resident falls which resulted in injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to deliver the amended findings on the complaint allegation above. LPA identified himself and explained the reason for the visit with staff.

Regarding the allegation, “Facility failed to address resident falls which resulted in injury.” The investigation revealed the following:

During the initial visit November 10, 2022, LPA Haley interviewed Executive Director (ED) Eric Jensen, four staff members and attempted to interview Resident 1 (R1). R1s responsible party was interviewed over the phone November 18, 2022. 4 of 6 individuals interviewed denied the allegation. Furthermore, during the initial visit November 10, 2022, LPA Haley received hospital discharge paperwork from Garden Grove Hospital dated November 7, 2022, and discharge paperwork from UCI dated November 9, 2022, that show R1 was sent to the hospital after each fall.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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-20221109162534

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 MEMORY CARE	FACILITY NUMBER: 306005901
	VISIT DATE: 04/18/2023

NARRATIVE

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Based on the information gathered during the investigation, document review and interviews, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC9099 (FAS) - (06/04)

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