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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006386
Report Date: 10/21/2024
Date Signed: 10/21/2024 01:25:48 PM

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
07/22/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240722145330
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: 144DATE:
10/21/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ephantus Warui, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Staff do not ensure that residents' incontinence needs are met
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 conducting a follow-up investigation into the allegations listed above. LPA was greeted and granted entry by administrator Ephantus Warui after stating the purpose of the visit.

An initial complaint investigation visit was conducted on July 31, 2024. LPA accompanied by administrator toured the facility's physical plant. The full resident census was requested and obtained in addition to the list of residents diagnosed with incontinence in both the memory care and assisted living. The logs for incontinence changes for a total of 72 residents diagnosed with incontinence were requested, obtained and reviewed during the visit. LPA additionally requested individual assessments and physician reports for a sample of five residents across memory care and assisted living and conducted two staff interviews and two residents interviews during the visit.

CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
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 5
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
07/22/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240722145330

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: 144DATE:
10/21/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ephantus Warui, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that the facility is maintained sanitary
Staff did not assist resident with arranging transportation for medical care
Staff do not ensure that residents are served water free from contamination
Staff do not monitor a resident for change in condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a follow-up investigation into the allegations listed above. LAP was greeted and granted entry by administrator Ephantus Warui after stating the purpose of the visit.

An initial complaint investigation visit was conducted on July 31, 2024. LPA accompanied by administrator toured the facility's physical plant. The full resident census was requested and obtained in addition to the list of residents diagnosed with incontinence in both the memory care and assisted living. The logs for incontinence changes for a total of 72 residents diagnosed with incontinence were requested, obtained and reviewed during the visit. LPA additionally requested individual assessments and physician reports for a sample of five residents across memory care and assisted living and conducted two staff interviews and two residents interviews during the visit.

CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20240722145330
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: 10/21/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099 During the present visit, LPA requested and obtained the current facility census and unit assignments, in addition to the list of residents for whom cash resources were being safeguarded due to the facility having been designated as the social security payee for the residents. Other residents are confirmed not to safeguard cash with the facility. One staff interview was conducted with facility administrator while twelve resident interviews were attempted or conducted.

Regarding the allegation that Staff do not ensure that the facility is maintained sanitary, the following has been concluded: Based on observation conducted during two facility visits, interviews with housekeeping staff and residents, it was determined that regular housekeeping services were being provided to residents throughout the building in a satisfactory way. Excessive wear-and-tear observed in some localized areas is scheduled to be addressed by the ongoing facility remodel which was observed and verified to be continuing during both facility visits.

Regarding the allegation that Staff did not assist resident with arranging transportation for medical care, the following has been concluded: While some residents decide to use transportation provided by relatives, friends or health insurance, all residents interviewed are aware of the availability of a transportation service provided by the facility. Use of the service was verified to happen during interviews.

Regarding the allegation that Staff do not ensure that residents are served water free from contamination, the following has been concluded: Water jugs are placed on dining tables prior to the lunch service being initiated. However, the presence of condensation on the jugs seen during both visits evidences that the water is poured in the pitchers just shortly before the meal service, precluding the possibility of contamination.

Regarding the allegation that Staff do not monitor a resident for change in condition, the following has been concluded: According to multiple residents interviewed during the present facility visit, timely and regular check-ins are being conducted by facility staff throughout the daytime and nocturnal shifts.

As a result, 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 or refute the alleged violations occurred. 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: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240722145330
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: 10/21/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099
During the present visit, LPA requested and obtained the current facility census and unit assignments, in addition to the list of residents for whom cash resources were being safeguarded due to the facility having been designated as the social security payee for the residents. Other residents are confirmed not to safeguard cash with the facility. One staff interview was conducted with facility administrator while twelve resident interviews were attempted or conducted.

Regarding the allegation that Staff do not ensure that residents' incontinence needs are met, the following has been concluded: Based on interviews and records reviewed conducted during the investigation, multiple residents reported that while timely and regular checks were being conducted on residents diagnosed with incontinence of bowel and/or bladder, occasional requests for assistance went unattended for multiple hours in multiple instances on the night time shift. Administrator stated that staffing had been increased to ensure this did not occur anymore.

As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B citation is cited on an attached form LIC9099-D and cleared during the present visit.

An exit interview was conducted and a copy of this report and appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240722145330
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: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
87625(b)(3)
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Per California Code of Regulations Section 87625 on Managed Incontinence: " the licensee shall be responsible for (...) (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence". This requirement is not met as evidenced by:
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Licensee confirmed that upon change of ownership, night shift scheduling had been increased to two staff members instead of one which ensured that nocturnal wait time had been reduced significantly. Updated schedules provided, deficiency cleared.
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Based on multiple interviews conducted, residents diagnosed with incontinence have reported having to wait multiple hours to get changed in some instances. This constitutes a potential risk to the health, safety and personal rights of 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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5