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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005901
Report Date: 12/12/2024
Date Signed: 12/12/2024 04:50:01 PM

Document Has Been Signed on 12/12/2024 04:50 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:		DENNIS ROBENIOLFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(714) 694-3205
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY: 120CENSUS: 45DATE:
12/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Dennis Robeniol TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to issue citations for deficiencies observed during unannounced visits made to the facility while investigating complaint control # 22-AS-20240909112643.

On Tuesday, September 17, 2024:

At 1:21pm, LPA Haley observed several trash cans in the hallway on the second floor. After speaking with two different staff members, it was confirmed pipes are leaking due to a plumbing issue that was resolved in the summer of 2023, and have been leaking for a while. Photos were taken.

At 4:25pm, LPA Haley observed the pull cord in the bathroom on the second floor in disrepair and nonfunctional. Photos were taken.

During today’s unannounced visit, while investigating complaint control number # 22-AS-20241205102328, while making observations in resident room number 332A, the room temperature was below regulation guidelines. One of the residents was observed in his room on the bed with a jacket on. The resident responded with I’m cold when asked how they were doing. LPA Haley observed the thermostat and it was covered with a plastic case. A key is needed to adjust the temperature. Photos were taken.

Towards the end of the unannounced visit LPA discovered 2 of 4 facility washer machines are in disrepair. Photos were taken.

As a result of today’s Case Management visit and observations made during the two unannounced visits, 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: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 2
Document Has Been Signed on 12/12/2024 04:50 PM - It Cannot Be Edited


Created By: Jerome Haley On 12/12/2024 at 03:47 PM
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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Executive Director Robeniol will schedule all necessary repairs or replace all non-fuctioning items (Leaking pipes on 2nd floor, broken washer machines, broken pull cords) in the facility. Proof of repairs and/or removal of non-fuctioning items will be provided to LPA Haley by 2:00pm on the POC due date.
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This requirement is not being met as evidenced by: Observations made by LPA during two different unannounced visits. This poses a potential health and safety risk for residents in care.
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Type B
12/19/2024
Section Cited
CCR87303(b)(2)

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(b) A comfortable temperature for residents shall be maintained at all times.
(2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature.
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Executive Director Robeniol will review the regulation section and email LPA Haley a signed statement acknowledging the regulation was reviewed and understood. ED Robeniol will also provide a plan to ensure the temperature in all resident rooms and common areas meet regulation guidelines. POC will be emailed to LPA Haley by 2:00pm on the POC due date.
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This requirement was not met as evidenced by: The temperature in resident room 332A was observed to be 67 degrees F. Photos were taken.
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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: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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