306005901-9-7-2023-22-AS-SSAS-CVWQLJ-20230922121602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 07/03/2023
Date Signed: 09/07/2023 07:53:38 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/04/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230404094217

FACILITY NAME:	BEACH TERRACE MEMORY CARE		FACILITY NUMBER:	306005901
ADMINISTRATOR:	EDWARDS, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	12282 BEACH BOULEVARD		TELEPHONE:	(503) 675-3925
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	120	CENSUS: 43	DATE:	07/03/2023
		UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Eric Jensen - Executive Director		TIME COMPLETED:	01:01 PM

ALLEGATION(S):

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Staff do not prevent residents from abusing other residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to Amend the report on the complaint allegation above. LPA Haley was granted entry and explained the reason for the visit with staff.
LPA Haley conducted follow up interviews with witnesses after the original report was provided July 3, 2023. Some of the witnesses who were originally interviewed were not able to be reached for a follow up interview.
Regarding the allegation above, during witness interviews it was discovered Resident 2 (R2) was abusive to other residents and staff. 6 of 7 witnesses provided information that confirm Resident 2 (R2) was abusive and displayed aggressive behavior. Document review support the information obtained during witness interviews and reveal R2 had aggressive episodes with residents and caregivers. It was documented on March 10, 2023, R2 hit a resident with his fist and attempted to hit a resident with a walker. On March 12, 2023, it was documented R2 was physically aggressive with other residents, and on March 13, 2023, it was documented R2 entered another resident’s room and made the resident cry.
Follow up interviews revealed there was no specific plan or directions given to staff to address R2’s behavior. On the morning of March 14, 2023, R2 had two behavior incidents before being sent to the hospital and being placed on a psych hold. R2 never returned to the community after being sent to the hospital.
Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1.
An exit interview was conducted and a copy of this report and appeal rights were provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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-20230404094217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (a) Residents in all residential care... shall have the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Executive Director Eric Jensen will review the Regulation Section (87468.1) and email LPA Haley once this is completed. ED Jensen will provide LPA Haley a detailed plan to prevent this from happening in the future. POC due date: Monday, July 10, 2023 at 12:00 Noon.
	8 9 10 11 12 13 14	This requirement is not being met as evidenced by witness interviews that confirm the facility failed to provide a specific plan or directions to staff to address the resident’s aggressive behavior.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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