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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006386
Report Date: 05/21/2026
Date Signed: 05/21/2026 04:27:16 PM

Document Has Been Signed on 05/21/2026 04:27 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SEASIDE TERRACEFACILITY NUMBER:
306006386
ADMINISTRATOR/
DIRECTOR:		PEDROZA, TRICIAFACILITY TYPE:
740
ADDRESS:9925 LA ALAMEDA AVETELEPHONE:
(714) 962-5531
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 250CENSUS: 147DATE:
05/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Ephantus WaruiTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Hanna Gough and Ruth Martinez made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with Administrator (AD) Ephantus Warui and discussed the purpose of the visit. The facility currently has 147 residents in care.

The facility is a two story building with resident apartments, bathrooms, activity room, dining room, medication room, memory care unit and staff offices. LPAs observed the memory care unit to be on the first floor with delayed egress doors that were found to be operational. LPAs observed the memory care unit to have resident apartments and an activity room/dining room with access to an outdoor shaded seating area. LPAs observed all resident bedrooms had the required components and furnishings. LPAs observed a hole in the wall of room 120 where exposed wires were observed. LPAs observed the bathrooms to have toilet paper, paper towels and non slip mats in the shower. LPAs tested the water to be between 106.7 to 119.1 degrees Fahrenheit. LPAs observed the laundry rooms to be locked and made inaccessible to residents in care. LPAs observed the extra linens to be on the second floor. LPAs observed toxins and chemicals to be in a locked room on the first floor. LPAs observed the emergency food and water supply to be in a closet on the first floor. LPAs observed the medication room on the first floor to be locked and made inaccessible to residents in care. LPAs observed the facility to have a completed first aid kit in the medication room. LPAs observed the kitchen to be clean and free of vermin. LPAs observed all appliances to be operational. LPAs observed the knives to be in the kitchen and made inaccessible to residents in care. LPAs observed the activities being conducted in the activity room during the duration of the inspection. LPAs observed the pull chord system to be operational with an immediate verbal response from the front desk and a 2 minute physical response time from care staff. LPAs observed an outdoor shaded seating area in the middle of the facility for resident enjoyment. Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SEASIDE TERRACE
FACILITY NUMBER: 306006386
VISIT DATE: 05/21/2026
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LPAs observed all walkways to be free of debris and obstructions. The carbon monoxide detector found on the second floor was found to be operational. LPAs observed fire extinguishers charged and with a service date of August 5, 2025, throughout the facility.

LPAs reviewed staff files and no discrepancies were observed and all staff files reviewed were found to have background clearances and associations to the facility. LPAs reviewed resident files and no discrepancies were observed. LPAs reviewed resident medications and no discrepancies were observed. LPAs reviewed a sprinkler inspection report from K Line Fire Equipment Co dated December 12, 2025, stating that the sprinkler system passed the inspection. LPAs reviewed a report from the City of Fountain Valley Fire Prevention Unit stating that on December 1, 2025, the facility smoke detectors passed inspection. LPAs reviewed an in service training was conducted on May 12, 2026, covering the disaster drill training.

Based on today’s inspection, deficiencies were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC 809D, and appeal rights were left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Hanna Gough
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2026 04:27 PM - It Cannot Be Edited


Created By: Hanna Gough On 05/21/2026 at 04:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SEASIDE TERRACE
FACILITY NUMBER: 306006386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPAs observing a hole with exposed wires in room 120 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2026
Plan of Correction
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Licensee fixed the hole during the course of the inspection and LPAs observed the patched job as well as the wires no longer being exposed. Citation cleared at the time of the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Hanna Gough
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2026


LIC809 (FAS) - (06/04)
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