306005901-1-30-2025-22-AS-LMOA-DGJ2LY-20250509173021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 01/30/2025
Date Signed: 01/30/2025 03:52:07 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
01/21/2025 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250121104701

FACILITY NAME:	BEACH TERRACE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	306005901
ADMINISTRATOR:	DENNIS ROBENIOL		FACILITY TYPE:	740
ADDRESS:	12282 BEACH BOULEVARD		TELEPHONE:	(714) 694-3205
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	120	CENSUS: 45	DATE:	01/30/2025
		UNANNOUNCED	TIME BEGAN:	07:50 AM
MET WITH:	Dennis Robeniol		TIME COMPLETED:	12:44 PM

ALLEGATION(S):

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The kitchen was left in an unsanitary manner while food was being served

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit regarding the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. During the visit LPA toured the facility to make observations and photos were taken. Some of the areas observed and photographed were the dining area, and the storage area where a supply of hand sanitizer and disinfectant wipes are stored.

Regarding the complaint allegation: The kitchen was left in an unsanitary manner while food was being served

During the investigation, 2 of 4 staff members interviewed provided information that supported the complaint allegation above. During interviews, it was discovered on the morning of January 19, 2025, a few used dishes and a pot what appeared to be a soup or stew was present in the kitchen area while breakfast was being served.
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: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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-20250121104701

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: 01/30/2025

NARRATIVE

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During interviews, it was discovered the dirty dishes that were in the kitchen area were from residents who eat in their room at night, and in the morning the resident(s) will bring their used dishes to the kitchen and drop them off on the counter to be cleaned.

Photos were provided and upon for further review of the photos, LPA observed dirty dishes in the kitchen as well as clean dishes in the kitchen at the time photos were taken. Further, after additional review of the photo, the amount of dirty dishes in the photo were consistent with the details provided during an interview with Staff 3 (S3). However, there was still a large pot of what appeared to be soup or stew, left out sitting on a warmer uncovered.

Based on the evidence gathered through interviews, and photo review, the preponderance of evidence standard has been met, therefore, the above allegation is SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250121104701

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: 01/30/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/30/2025 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.	1 2 3 4 5 6 7	Licensee understands the regulation requirement and agrees. All areas of the kitchen were clean during the visit and no further action is required
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by photos that reveal dirty dishes and a pot of leftover food (soup/stew) was present in the kitchen while breakfast was being served.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 01/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC9099 (FAS) - (06/04)

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