306005901-6-16-2026-22-AS-KSGH-DVMR4S-20260703124202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 06/16/2026
Date Signed: 06/16/2026 03:18:17 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
09/23/2025 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250923151212

FACILITY NAME:	BEACH TERRACE ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	306005901
ADMINISTRATOR:	CHRISTINE CHON		FACILITY TYPE:	740
ADDRESS:	12282 BEACH BOULEVARD		TELEPHONE:	(714) 694-3205
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	0	CENSUS: 67	DATE:	06/16/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Minyoung "Nicole" Kim		TIME COMPLETED:	02:24 PM

ALLEGATION(S):

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Resident had multiple falls resulting in hospitalization due to a head injury
A lack of care resulted in complaints of pain and discomfort due to severely overgrown toenails

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the allegations listed above. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit.

The complaint investigation was initiated by LPA Jerome Haley on September 24, 2025, regarding a complaint filed on September 23, 2025. The complaint was investigated by the Department and consisted of a review of resident records, interviews with facility staff, multiple witnesses including a state Ombudsman, and a placement agency representative, and a review of hospital records from Los Alamitos Medical Center dated August
A lack of care resulted in complaints of pain and discomfort due to severely overgrown toenails 27, 2025, and West Anaheim Medical Center dated September 2-3, 2025.

Regarding the allegation: Due to a lack of care and supervision, a resident fell multiple times and sustained a head injury
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

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-20250923151212

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: 06/16/2026

NARRATIVE

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During the investigation 5 of 7 witness interviews confirmed the complaint allegation as it was reported.
On August 27, 2025, Resident 1 (R1) was sent to the hospital and diagnosed with an acute head injury and scalp laceration as a result from a fall sustained at Beach Terrace Memory Care on August 27, 2025. The resident arrived around 6:40 pm at Los Alamitos Medical Center and was discharged back to Beach Terrace Memory Care a few hours later around 9:10 pm. When discharged from Los Alamitos Medical Center R1 was given orders to follow up with their primary care provider within 5 to 7 days to discuss and further evaluate the injury, and for staple/suture removal and wound check.
However, document review reveals that R1 suffered at least two additional falls prior to the scheduled September 8, 2025, follow up visit to have the staples removed from their head. Incidents evidenced include a fall on August 28, 2025, the day after being released from the hospital after being treated for the initial fall on August 27, 2025, that resulted in a head injury that required three staples. Document review revealed that R1 was pushed to the ground by another resident and landed on their back around 7:00 am on August 27, 2025.
On September 2, 2025, R1 suffered a fall and was sent to the hospital after being discovered on the ground around 2:40 pm in their bathroom and bleeding from the ear. R1 was sent to West Anaheim Medical Center and diagnosed with a fall, closed head injury, and UTI. R1 was treated and released the following day: September 3, 2025, with orders to follow up with their PCP in one week.
The document was consistent with what was discovered during witness interviews. R1 suffered three falls within six days, sustained head injuries and it was discovered R1’s toenails were severely overgrown.
None of the seven individuals interviewed disputed or challenged any incidents as they were reported. Further, document review revealed information and details that were consistent with witness interviews.

Regarding the allegation: A lack of care resulted in complaints of pain and discomfort due to severely overgrown toenails

During the investigation 7 of 7 witness interviews confirmed the complaint allegation as reported. While R1 was in the hospital on August 27, due to a fall and sustaining a head injury it was reported by a family member that R1 complained of pain to their feet while at Los Alamitos Medical Center.

Continued on LIC9099C Page 2 of 3

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250923151212

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: 06/16/2026

NARRATIVE

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When R1 socks were taken off, R1's toenails on both feet were discovered to be severely overgrown. The toenails were so overgrown, several toenails began to wrap around the toes of R1. The toenails were discolored and toenails were growing underneath the older overgrown toenails.

Photos of both feet taken at Los Alamitos Medical Center August 27, 2025, were provided.
After the discovery of the overgrown toenails, Los Alamitos Hospital did not have a podiatrist on the staff and it would take the hospital a couple days to get a podiatrist for R1, so a family member of R1 clipped the residents toenails while they were in the hospital. The family member stated they did not want R1 to be in any additional pain while they found a podiatrist.

R1 toes were trimmed August 27, 2025, and after interviews with multiple individuals, R1 eventually was seen by a podiatrist and continues to receive podiatry care every other month since the fall, injury, and discovery of the overgrown toenails.

Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, both allegations are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.

An Enhanced Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f).

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

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250923151212

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: 06/16/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2026 Section Cited CCR 87464(a)(1)(f)	1 2 3 4 5 6 7	87464 Basic Services (a) The services provided by the facility shall... promote... independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility had inplemented several measures to help address fesident falls including lower beds, floor mats, night lights, encourage the use of bed side commode and urinal, and increased resident checks by the caregivers. No additional action is required.
	8 9 10 11 12 13 14	R1 sustained multiple fallswhile in care including a fall that took place after the August 27, 2025 fall that resulted in ahead injury and hospitalization.	8 9 10 11 12 13 14
Type A 06/17/2026 Section Cited HSC 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical & Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility has already implemented regular check ups for R1 by a podiatrist everyother month. No additional action is required.
	8 9 10 11 12 13 14	When R1 was sent to the hospital after a fall, it was discovered the residents toenails were severely overgrown. The resident was complaining of pain to the feet when the overgrown toenails were discovered.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026

LIC9099 (FAS) - (06/04)

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