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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 07/10/2025
Date Signed: 07/10/2025 02:30:32 PM

Unfounded


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
01/17/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 22-AS-20240117131548
FACILITY NAME:BEACH TERRACE MEMORY CAREFACILITY NUMBER:
306005901
ADMINISTRATOR:ERIC JENSENFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(503) 675-3925
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 51DATE:
07/10/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Christine ChonTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained a fall resulting in death due to neglect.
Facility did not safeguard resident's belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted this unannounced complaint visit to deliver the results of the allegations above. The above allegations came in on 01/17/2024.

The Department conducted an investigation into the allegation related to neglect contributing to R1’s death.

Based on the investigation, the Department obtained and reviewed medical records and R1’s death certificate. The primary cause of death listed was pneumonia, and there were no other contributing conditions listed.

Based on the evidence gathered, the Department finds that the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
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 2
Control Number 22-AS-20240117131548
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 MEMORY CARE
FACILITY NUMBER: 306005901
VISIT DATE: 07/10/2025
NARRATIVE
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The department conducted interviews and reviewed the resident’s file. The resident’s personal property and valuables list in the admission agreement declined a formal inventory of their belongings upon move-in. Because the personal belongings inventory by the facility was declined by the responsible party upon move-in, the allegation is unfounded.

Based on the evidence gathered, the Department finds that the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2