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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006386
Report Date: 07/01/2025
Date Signed: 07/01/2025 02:58:07 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
06/18/2025 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250618153244
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: 155DATE:
07/01/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Ephantus Warui, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff refused to accept resident back to the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to deliver findings related to the investigation of the complaint allegation identified above. LPA arrived at facility and was greeted and granted entry by staff. LPA spoke with Ephantus Warui, Administrator and explained the purpose of the visit.

Findings are based upon this investigation which included interviews conducted and resident file record review.
It is alleged that facility staff refused to accept resident back to the facility. Interview with Administrator stated that resident (R1) had gone to the hospital on June 17, 2025. On June 18, 2025, R1 was ready to be discharged, and Administrator refused to accept R1 back to the facility. Administrator stated that they had received a call 24 hours later that R1 was ready to be discharged and Adminsitrator indicated that
continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
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 3
Control Number 22-AS-20250618153244
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: 07/01/2025
NARRATIVE
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they would not be taking R1 back until a medication assessment was completed. During the interview with Administrator allegation was confirmed. Based on information obtained R1 remained in the emergency room from June 17, 2025, to on or about June 25, 2025, until R1 responsible party found R1 new placement.

During the course of the investigation, there was sufficient evidence to substantiate the allegation. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator and a copy of this LIC9099 and LIC9099-D, along with a copy of the appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250618153244
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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2025
Section Cited
CCR
97224(a)(4)
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87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed...: (4)If, after admission, it is determined that the resident has a need to not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person
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R1 is already at a new facility. Administrator stated they will review Section cited and submit a statement of understanding, and implement written protocol steps which will assist him with eviction procedures. Administrator to send statement and written protocol to LPA by POC due date.
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who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement was not met as evidenced by: interview with Administrator stated the they refused to accept R1 back to the facility, this poses a potential 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: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3