306005901-12-18-2024-22-AS-MSTC-DCC4A7-20241226175529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 12/18/2024
Date Signed: 12/18/2024 05:05:17 PM

Unsubstantiated

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
11/06/2024 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20241106140703

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: 43	DATE:	12/18/2024
		UNANNOUNCED	TIME BEGAN:	07:00 AM
MET WITH:	Dennis Robeniol- Executive Director Edwin Guzman- Memory Care Program Director		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

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Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of concluding the investigation and delivering the findings into the above allegation. LPA met with Executive Director (ED Dennis Robeniol and explained the reason for the visit. During the course of the investigation conducted on November 14, 2024, and December 12, 2024, LPA conducted interviews with a total of two residents, five staff, and four individuals as well as obtained the Resident/Staff Rosters, Identification and Emergency Information, Physician’s Reports, Appraisals/Care Plans, Care Staff Assignments, Narrative Charting/Resident Assessments, Timecards, and other pertinent documentation.

The investigation revealed the following:
Regarding the allegation, Resident sustained injuries while in care, it was reported that on November 4, 2024, on or approximately 11:54pm, former roommates Resident #1 (R1) and Resident #2 (R2), were involved in a physical altercation resulting in R1 sustaining an injury to the lip and torso.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

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-20241106140703

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: 12/18/2024

NARRATIVE

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It was alleged that R1 had been allegedly “sucker punched” on the right side of the face and was repeatedly hit with the walker by R2. Two out of the two residents, four out of the five staff, and two out of the four individuals that were interviewed confirmed observing R1 with a lip injury caused by the alternation but not to the torso or head. R2 also confirmed punching R1 on the mouth causing an injury to the lip area. However, R2 indicated that they had thrown the punch in return after being struck first but denied using the walker to hurt R1. Based on the staff interviews, four out of the five staff confirmed R1 refusing to seek medical treatment offered by the facility staff and the paramedics which was consistent with the incident report dated November 11, 2024 and Narrative Charting dated November 5, 2024.

Based on the records that were reviewed, R1 is diagnosed with Dementia and may be “verbal and aggressive at times” according to the Physician’s Report dated August 30, 2024. The care level documented on the Resident Assessment dated October 1, 2024, requires no additional status checks as well as R2 per their Resident Assessment dated July 12, 2024. Routine checks of every two hours were required for R1 and R2 per Resident Care Director (RCD) Alysia Noriega. The two staff who were working the evening of November 4th, confirmed conducting status checks at the start of their shifts. The narrative charting notes R1 was hit on the head with a walker twice from both accounts, however there were "no signs of injury, bruising, pain, or bleeding" observed besides the lip and R1's "vitals were good" per the paramedic’s assessment. R1’s representative also did not corroborate with R1's statement of being repeatedly hit with a walker, as they had indicated that it would be fatal due to their medical condition. It was also revealed R1 having a history of embellishing stories.

Based on the investigation, it is determined that although R1 has sustained an injury to the lip area, there were no evidence to prove that R1 had sustained additional injuries to the torso or head. Facility conducted routine checks and responded timely reporting the medical emergency to law enforcement and first responders. However, resident denied receiving medical treatment which is their personal right. The evidence obtained did not corroborate due to a lack of care and/or supervision.

Therefore, based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Resident sustained injuries while in care is deemed UNSUBSTANTIATED. An exit interview was conducted with Memory Care Program Director Edwin Guzman, and a copy of this report and the LIC811 were provided at exit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024

LIC9099 (FAS) - (06/04)

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