306006386-4-18-2025-22-AS-SSAS-DG32CF-20250424171640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006386
Report Date: 04/18/2025
Date Signed: 04/18/2025 01:19:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
01/24/2025 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250124100002

FACILITY NAME:	SEASIDE TERRACE		FACILITY NUMBER:	306006386
ADMINISTRATOR:	PEDROZA, TRICIA		FACILITY TYPE:	740
ADDRESS:	9925 LA ALAMEDA AVE		TELEPHONE:	(714) 962-5531
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	250	CENSUS: 155	DATE:	04/18/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ephantus Warui, Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not dispense medication to resident as prescribed.

Staff did not provide residents with adequate food service.

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the two allegations listed above. LPA was greeted and granted entry by front desk staff after stating the purpose of the visit. Administrator Ephantus Warui was present and assisted with the visit.

The initial complaint investigation was conducted on January 31, 2025. During the visit, LPA requested and obtained the facility's current resident census as well as the list of residents under medication management. LPA requested and obtained resident records for five individuals present at the facility. Medication administration records reviewed for all five individuals. A tour of the facility's kitchen and review of the current menus conducted.

CONTINUED ON FORM LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025

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-20250124100002

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/18/2025

NARRATIVE

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CONTINUED ON FORM LIC9099
During the present visit, LPA requested the resident census. A review of the medication administration records, prescription orders, PRN dispensation logs and centrally stored medication was conducted for a sample of 8 residents on medication management along with an interview of the facility medication technician on duty. LPA additionally observed the lunch service being performed. Six resident interviews were also conducted during the visit.

Regarding the allegation that Staff did not dispense medication to resident as prescribed, the following has been concluded: Based on interviews with staff members, review of the medication centrally stored in the medication room, review of medication administration records and resident interviews, no discrepancies between the amount stored in bubble packs and the quantities dispensed were evidenced to indicate staff failed to dispense prescribed medication timely. PRN doses are adequately being logged on sheets attached with the medication upon dispensation. Per facility policy, only doses not delivered per resident refusal or absence are being logged, with other doses assumed to be dispensed. A majority of residents interviewed stated they had no perceived issues with the assistance received for their medication self-administration

Regarding the allegation that Staff did not provide residents with adequate food service, the following has been concluded: Based on staff and resident interviews along with a review of facility menus and observation of meal service in progress, it was observed that quantities and variety of food being provided were satisfactory. Residents interviewed confirmed that meal services are adequate in quantity. Seconds can be provided on demand, and accommodations are confirmed to be offered.

Based on the present investigation, the allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025

LIC9099 (FAS) - (06/04)

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