306005901-10-25-2023-22-AS-SSAS-CX62L4-20231031172855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005901
Report Date: 10/25/2023
Date Signed: 10/25/2023 03:39:07 PM

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
08/25/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230825151110

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: 46	DATE:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Eric Jensen - Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Lack of supervision resulted in resident falling and sustaining an injury.

INVESTIGATION FINDINGS:

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LPA Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit.

Regarding the allegation: Lack of supervision resulted in resident falling and sustaining an injury.
The investigation into the complaint allegation above revealed, on August 23, 2023 around 7:00PM Resident 1 (R1) suffered an unwitnessed fall near the caregiver break room on the third floor of the facility. R1 was sent to West Anaheim Medical Center for pain to the head due to the fall. R1 was then transferred to Kaiser Anaheim for a higher level of care. At Kaiser Anaheim, R1 was treated for a cervical (neck) vertebral fracture due to the fall and ordered to stay in the cervical collar for the next three months.

8 of 9 witness confirmed R1 had an unwitnessed fall on August 23, 2023, and returned to the community with a neck brace.
Continued on LIC9099C

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230825151110

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
	VISIT DATE: 10/25/2023

NARRATIVE

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The fall was unwitnessed and there was not much detail about how the incident occurred. Interviews and document review revealed the resident was found on the floor with eyes closed and expressed pain to the back and neck to paramedics. R1’s after visit summary from Kaiser dated August 24, 2023 revealed a diagnosis of Cervical (neck) Vertebral Fracture.

On August 23, 2023, when R1 fell and sustained an injury to the neck, none of the staff on duty witnessed the fall. It’s unclear what the resident was doing at the time of the fall, it’s unclear who was present when R1 fell, and it’s unclear why none of the staff on duty was present when R1 who has a history of falling, fell in a common area. Witness interviews, as well as document review reveal R1 has had several falls. Witness interviews revealed there was no plan and/or directions given to or discussed with staff to prevent R1 from falling.

Based on the evidence gathered during 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.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230825151110

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: 10/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/27/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 (f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) Health and Safety Code	1 2 3 4 5 6 7	Executive Director Eric Jensen will send a detailed plan that outlines the steps that will be taken to prevent and/or reduce the number of unwitnessed falls occurring in the community. The detailed plan will be emailed to LPA Haley by Friday, October 27, 2023 at 1PM.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by R1 who is a known fall risk, having an unwitnessed fall in a common area of the facility. This poses a potential health and safety risk to residents in care.	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: 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

LIC9099 (FAS) - (06/04)

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