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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006386
Report Date: 10/15/2024
Date Signed: 10/15/2024 11:36:09 AM

Substantiated


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
10/08/2024 and conducted by Evaluator Lydia Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241008150330
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: 142DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ephantus "Epi" WaruiTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not safeguard a resident's personal belonging
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Lydia Martinez conducted an unannounced visit to initiate a complaint investigation into the allegation listed above. LPA met with Administrators Tricia Pedroza and Ephantus "Epi" Warui and reason for visit was discussed.

Allegation: Facility failed to safeguard resident’s personal property

On or about 09/17/2024, Resident 1 (R1) returned from a Skilled Nursing facility. R1 had not noted the gym equipment that was on R1's balcony was gone. On or about 10/8/2024 when he noted gym equipment was gone, R1 reported it to AD Epi. LPA reviewed R1's file and the property log for R1. R1's property log had not been updated to reflect the gym equipment, however, interviews with Maintenance staff stated he was the one who helped R1 put together gym equipment 2+ years ago and was on R1's balcony up until it was thrown out during a clean up while R1 was out of the facility. (see LIC9099C)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 22-AS-20241008150330
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: 10/15/2024
NARRATIVE
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Both Administrators confirmed gym equipment was thrown out by mistake when facility was going through clean up/construction couple months ago. AD Epi stated they have offered to reimbursed the resident for failing to safeguard R1's personal property (gym equipment).

Based on the information gathered the preponderance of evidence standard has been met, therefore, the allegation, facility staff is not safeguarding resident's personal items, is found to be Substantiated. Violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted and a copy of this report along with citation and Appeal Rights was sent to email on file.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241008150330
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2024
Section Cited
CCR
87217(b)
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Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement was not met as evidenced by:
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Licensee to replace/reimburse R1's gym equipment and provide proof to LPA by POC due date.
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Facility staff threw away R1's gym equipment while R1 was out. 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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3