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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006386
Report Date: 04/01/2025
Date Signed: 04/01/2025 12:52:43 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
03/24/2025 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20250324082636
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:
04/01/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Tricia Pedroza, Licensee and Ephantus Warui, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff do not ensure residents call button is in reach
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit at 8am to investigate a complaint received in our Regional Office on March 24, 2025. LPA met with Tricia Pedroza, Licensee and Ephantus Warui, Administrator and explained the purpose of the visit.

LPA requested the following documents: Resident roster, Personnel Report,and Unusual Incident Reports. LPA interviewed three of three residents regarding care provided and four of four staff members regarding care given. LPA toured the facility and entered five of five resident rooms and discovered one room did not have a working call button and resident was not able to reach it. At the end of the visit, call button was repaired and tested by LPA and resident's bed was moved to reach the call button on the wall.

Based on LPA observations and interviews, the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Tricia Pedroza, Licensee and a copy of this report was given to the facility along with a copy of the LIC 9099-D and Appeal Rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
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 2
Control Number 22-AS-20250324082636
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: 04/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2025
Section Cited
CCR
87303(i)(1)(B)
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87303(i) Facilities shall have signal systems which... (1) All facilities licensed for 16 or more...shall have a signal system which...(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
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The Maintenance Director immediately repaired the resident's signal system and moved the resident's bed so that the resident could reach the wall system. A cord was also in the resident's bed with a call button.
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Based on LPA observation and interviews the licensee did not ensure call buttons were within reach, and in working order, in one of one resident rooms which poses an immediate health and safety risk to persons 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: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2