<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006386
Report Date: 11/15/2023
Date Signed: 11/15/2023 11:55:33 AM


Document Has Been Signed on 11/15/2023 11:55 AM - 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:SEASIDE TERRACEFACILITY NUMBER:
306006386
ADMINISTRATOR:PEDROZA, TRICIAFACILITY TYPE:
740
ADDRESS:9925 LA ALAMEDA AVETELEPHONE:
(714) 962-5531
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:250CENSUS: 134DATE:
11/15/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Tricia Pedroza, Ephantus WaruiTIME COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Tricia Pedroza and Administrator (AD) Ephantus Warui, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 07/20/2023. This is a change of ownership with persons in care.

During the inspection, LPA, AP, and AD observed the following: Structure: facility is a large commercial facility. There is one building with three stories. The first story contains resident rooms, offices, common areas, the kitchen, and the memory care unit with delayed egress. The second story contains resident rooms and common areas. The basement level contains parking and storage areas. There is a central open-air courtyard. The medication room is on the first floor. There are 18 bedrooms in the memory care unit and 107 bedrooms in the assisted living section. Resident rooms contain their own bathrooms. Facility telephone number is (714) 962-5531. Resident Bedrooms: the resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lights, chairs, linens, and storage for 14 resident bedrooms inspected. Bathrooms: were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees F and 118 degrees. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: 2 days perishable and 7 days nonperishable food supply reviewed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the two housekeeping closets. Medications are locked in medication carts inside the medication room. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files: LPA reviewed 14 resident files and 10 staff files. Fire clearance was approved by the Fountain Valley Fire Department on 09/12/2023 for 88 ambulatory, 156 non-ambulatory, and 6 bedridden.

CONTINUED.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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


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: SEASIDE TERRACE
FACILITY NUMBER: 306006386
VISIT DATE: 11/15/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Courtyard exit gates are operational and unlocked. Courtyards have shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. Facility is currently operating under the liability insurance of current facility SEASIDE TERRACE RETIREMENT COMMUNITY (306004415). AP will switch liability insurance to new facility once the application is approved.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2