306005901-7-11-2025-22-AS-MSEY-DJLT63-20250715142628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 07/11/2025
Date Signed: 07/11/2025 11:57:54 AM

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
10/29/2024 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 22-AS-20241029145421

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: 51	DATE:	07/11/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Christine Chon		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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1. Resident fell resulting in a fracture due to staff neglect.
2. Resident was severely malnourished due to staff neglect.
3. Resident was severely dehydrated due to staff neglect.
4. Resident sustained an unstageable pressure injury due to staff neglect.
5. Facility staff failed to provide resident records.

INVESTIGATION FINDINGS:

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The department conducted the investigation into the allegations above. The department reviewed medical records, facility records, and conducted interviews. This complaint came in October 2024.

1. Title 22 Regulations does not require staff to have residents in line of sight or within earshot 24 hours a day, seven days a week. Title 22 Regulations require facilities to assess residents and determine how much supervision and care a resident requires. Records and interviews do state one resident had a fall that resulted in a leg fracture. Interviews with staff stated they check on residents a minimum of every two hours and the checks are adjusted according to a resident’s needs. Facility records and interviews indicate the resident was able to walk around the facility without assistance. The resident was provided a walker by the facility and staff stated the resident did not like to use the walker. Staff were instructed to remind the resident to use the walker if the resident was seen not using it. The resident was unavailable for interview.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

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-20241029145421

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: 07/11/2025

NARRATIVE

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Because the facility records and staff interviews indicate the resident was able to walk without assistance, it cannot be determined if the fall was a result of staff neglect.

2. & 3. Interviews with staff and witnesses stated the resident started to decline quickly and refused to eat and drink. Staff are not allowed to force a resident to eat and drink. Witnesses stated the resident was declining and observed food and liquids in the resident’s room. Other interviews stated staff did not take the time to ensure resident ate all that the resident wanted to eat. The department cannot prove or disprove the resident became severely dehydrated and malnourished due to staff neglect.

4. A review of the records showed the resident started hospice care with one hospice agency and ended with another one. The resident had a fall that resulted in the resident becoming bedridden and required to be turned every two hours. The change in condition was noted in the resident’s hospice care plans but a log was not completed by staff. A log is not required per Title 22 regulations. Interviews also stated the resident declined quickly and was in poor health. Because logs to keep record of when a resident is turned per the care plan is not required and the resident’s health condition it cannot be determined if the resident developed an unstageable pressure injury due to neglect.

5. Per Title 22 regulations, resident records shall be made available to a person designated with the written consent of the resident. LPA was unable to review the resident's record. LPA was unable to determine what records were requested by the resident's responsible party.

Therefore, LPA finds the allegation to be "unsubstantiated." A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the violation occurred.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2025

LIC9099 (FAS) - (06/04)

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