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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005901
Report Date: 12/04/2024
Date Signed: 02/11/2025 04:52:53 PM

Document Has Been Signed on 02/11/2025 04:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
306005901
ADMINISTRATOR/
DIRECTOR:		ERIC JENSENFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(530) 242-8300
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY: 120TOTAL ENROLLED CHILDREN: 0CENSUS: 45DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Dennis Robeniol - Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analysts (LPAs) Jerome Haley and Eboni Bentley arrived at the facility unannounced for the purpose to conduct the Required 1 Year Annual Inspection. LPAs were greeted and granted entry by one of the senior staff members on duty as the business/reception area was closed upon arrival.

The facility is licensed with a capacity of 120 residents and maintains a hospice waiver of 20 residents. During the annual inspection, the resident census was 45. LPA Haley and LPA Bentley conducted a tour of the physical plant and observed the following:

This is a two-story commercial building comprised of an Assisted Living (AL) Memory Care Unit. LPA’s inspected 8 random resident bedrooms which had all the required elements with ample lighting. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. The hot water temperature measured within the range of 105 -112.4 degrees Fahrenheit. LPAs inspected the kitchen and the dining area. A first aid kit with all the required elements was observed in the office of the Resident Care Coordinator (RCC) on the second floor. There’s also a first aid kit in the med room on the third floor. Facility maintains ample supply of two-day perishables food items and seven-day supply of non-perishables food items. Emergency food and water was observed. Cleaning chemicals and toxins was in a sotrage room on the second floor.

Edison Fire Protection conducted an annual inspection of the Fire/Sprinkler system on February 12, 2024 which was verified on the inspection report. LPAs toured the outside grounds, there was sufficient seating and shading for the residents, and the walkways were free of obstruction.

Continued on LIC809C
Lourdes MontoyaTELEPHONE: (714) 703-2870
Jerome HaleyTELEPHONE: 714-703-2840
DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/04/2024
NARRATIVE
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LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size posted in the entry way. Facility maintains a current liability insurance.

Five resident files and five staff files were reviewed. No discrepancies noted. LPAs reviewed two staff files. No discrepancies noted. Interviews were conducted with seven out of eight residents as one resident refused. The two staff interviews were not conducted as they had ended their shift. The medications and the Medication Administration Records (MARs) were reviewed for 5 residents. No discrepancies noted.

During the visit, LPA Haley advised the Executive Director on the importance of keeping enough emergency food and water, and the importance of conducting emergency evacuation drills at least quarterly for staff on each shift.

Based on LPAs observations, deficiencies will be cited for violations of Title 22, and a Technical Advisory (TVs) will be issued as a result of today’s inspection.

An exit interview was conducted and a copy of this report, and appeal rights were provided.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2025 04:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made during the annual inspection and interview confirmation, the licensee did not comply with the section cited above which poses a potential health risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Executive Director Robeniol stated an order placed to stock the emergency food an water supply. ED Robeniol will email LPA Haley a copy of the invoice once the items are purchased no later than 1:00pm on the POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses a potential health and/or safety risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Executive Director Robeniol agrees to schedule an emergency evacuation drill for staff on all shifts. ED Robeniol will schedule the drill and send LPA Haley the dates and times of the scheduled evacuation drill(s) no later than 1:00pm Friday, December 13, 2024. A copy of the sign in sheet for the evacuation drill will be emailed to LPA Haley after completion of the evacuation dirll.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes MontoyaTELEPHONE: (714) 703-2870
Jerome HaleyTELEPHONE: 714-703-2840

DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024

LIC809 (FAS) - (06/04)
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