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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005901
Report Date: 10/25/2023
Date Signed: 10/25/2023 03:40:46 PM


Document Has Been Signed on 10/25/2023 03:40 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BEACH TERRACE MEMORY CAREFACILITY NUMBER:
306005901
ADMINISTRATOR:ERIC JENSENFACILITY TYPE:
740
ADDRESS:12282 BEACH BOULEVARDTELEPHONE:
(503) 675-3925
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 46DATE:
10/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Eric Jensen - Executive DirectorTIME COMPLETED:
02:19 PM
NARRATIVE
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During the investigation into complaint control number 22-AS-20230825151110 it was discovered the facility failed to report the fall and/or injury to the Regional Office.

All serious incidents should be reported to the Regional Office within 7 days. Beach Terrace Memory Care failed to report a resident was sent to the hospital after an unwitnessed fall with complaints of pain to the back and neck. The resident returned to the facility on August 25, 2023, with a diagnosis: Injury Due to Fall – Cervical (Neck) Vertebral Fracture.

There was no incident report regarding Resident 1’s fall August 23, 2023, sent to the Regional Office.

As a result of today’s Case Management visit, a deficiency will be cited.

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

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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 10/25/2023 03:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
87211(a)(1)(B)

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Reporting Requirements
(a) Each licensee shall furnish...reports as the Department may require, including, but not limited to...
(1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified... below. This report shall include the resident’s name, age...disposition of the case.
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Executive Director Eric Jensen will hold an in-service training for all staff on Reporting Requirements.
A sign in sheet and outline of the topics covered and duration of the in-service training will be emailed to LPA Haley by the POC due date.
Executive Director Eric Jensen will send a detailed plan that outlines the steps that will be taken to ensure all serious incidents are reported. The detailed plan will include the following:
• Who will be responsible for sending incident reports
• A backup staff member responsible for reporting serious incidents.
• Incident reporting time frames.
The in-service training sign-in sheet, in-service training outline, and detailed plan on reporting serious incidents will be emailed to LPA Haley by Wednesday, November 01, 2023 at 1PM.
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This requirement is not being met as evidenced by the facility failing to report R1's fall and injury. This poses a potential health 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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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