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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005901
Report Date: 07/03/2023
Date Signed: 07/03/2023 01:39:57 PM


Document Has Been Signed on 07/03/2023 01:39 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BEACH TERRACE MEMORY CAREFACILITY NUMBER:
306005901
ADMINISTRATOR:EDWARDS, CYNTHIAFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(503) 675-3925
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 43DATE:
07/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Eric Jensen - Executive DirectorTIME COMPLETED:
01:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley made conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20230404094217.

During the complaint investigation mentioned above, it was discovered there were incidents involving aggressive behavior displayed by Resident 1 (R1) that were not reported to the department. The incidents took place in March 2023 and there is no evidence of any of the incidents were reported to the department as required.

As a result of todays visit, a deficiency will be cited during today's Case Management visit.

An exit interview was conducted and a copy of this report, LIC809D, LIC811, and appeal rights were provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
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 2


Document Has Been Signed on 07/03/2023 01:39 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BEACH TERRACE MEMORY CARE
FACILITY NUMBER: 306005901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2023
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) a written report shall be submitted to the licensing agency... within seven days... (D) Any incident which threatens the welfare, safety, or health of any resident, such as... or unexplained absence of any resident.
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Executive Director Eric Jensen will review Regulation Section 87211 (Reporting requirements and email LPA Haley a plan on preventing this from happening again, and who will be responsible for sending incident reports to the Regional Office.
POC due date: July 10, 2023 at 12:00 Noon.
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This requirement is not being met as evidenced by review of incident reports sent to the department. There was no incident report that mentioned R1 sent to the regional office. LPA spoke with staff and they could not provide the incident reports that were sent to the Regional Office.
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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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2