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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005901
Report Date: 10/30/2024
Date Signed: 10/30/2024 05:08:01 PM

Document Has Been Signed on 10/30/2024 05:08 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: 120CENSUS: 46DATE:
10/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Executive Director Dennis RobeniolTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to issue citations for deficiencies observed on Saturday, October 26, 2024 around 12:00 noon.

During the case management visit, LPA Haley toured the interior of the facility and made several observations. During the tour with Executive Director Robeniol and the Resident Services Director, LPA Haley entered 7 resident rooms: four rooms on the third floor, including room 310 and three rooms on the second floor. Photos were taken.

As a result of today’s Case Management visit and observations made Saturday, October 26, 2024, deficiencies will be cited per California Code of Regulation Title 22.

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

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2024 05:08 PM - It Cannot Be Edited


Created By: Jerome Haley On 10/30/2024 at 10:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
87307(d)(3)(A)(B)

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87307(d)(3)(B) – Personal Accommodations and Services
(d) The following space and safety provisions shall apply at all facilities:
(3) All persons shall be protected against hazards with the facility through provisions of the following:
(A)Protective devices such as nonslip material on rugs.
(B) Information and instruction regarding life protection and other appropriate subjects.
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A safety lock was placed on the window in room 310. All rooms will be checked to confirm all windows have safety locks in place and Executive Director Dennis Robeniol agrees to send LPA Haley a confirmation email confirming there’s a lock on the window in each room by the POC due date.
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This requirement is not being met as evidenced by:
On Saturday, October 26, 2024 around 12:00 noon, the window in room 310 did not have a safety lock to prevent the window from opening all the way. This poses a healthy and safety risk to residents in care.
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2024 05:08 PM - It Cannot Be Edited


Created By: Jerome Haley On 10/30/2024 at 10:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
87303(a)

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87303 (a) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Executive Director (ED) Dennis Robeniol states a screen will be placed on the window of room 212a by the POC due date, ED Robeniol will email LPA Haley a photo of the screen once installed.
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This requirement is not being met as evidenced by:
While inspectin resident bedrooms LPA Haley, Executive Director Robeniol, and the Resident Service Director observed resident room #212 missing a window screen. A photo was taken. This poses a potential safety risk to resident in care.
This
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Type B
11/01/2024
Section Cited
CCR87405(A)

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87405 (a) – Administrator Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises... to the management and administration of the facility… there shall be a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility…The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
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Executive Director (ED) Dennis Robeniol will designate a back up administrator who will be available when the Executive Director is not working and/or unavailable. ED Robeniol will fill out an LIC308 and email to LPA Haley by the POC due date.
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This requirement is not being met as evidenced by:
On Saturday, October 26, 2024 there was no administrator or designated back up administrator in the building. This poses a potential health, safety, and personal rights risk to residents in care.
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024


LIC809 (FAS) - (06/04)
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