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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006386
Report Date: 07/14/2025
Date Signed: 07/14/2025 12:58:09 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
02/29/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 22-AS-20240229081034
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: 156DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ephantus WaruiTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff did not seek timely medical assistance.
Facility force fed the resident resulting in injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted this unannounced complaint visit to deliver the results of the allegations above. The above allegations came in on 02/29/2024.

The Department conducted an investigation into the allegations above.

Resident #1 (R1) moved into the facility in January 2019. At that time R1 was ambulatory and did not need a walk or wheelchair, was able to transition to and from bed independently and needed little assistance with their Activities of Daily Living (ADLs). It was noticed on 02/05/2024 that R1 had a small cut on the left side of their face, but no bruises, it was later determined on the same day that R1 had banged their forehead on the countertop in the facility's dining room area. R1 was assessed by the Licensed Vocational Nurse (LVN) who found no injuries.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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 4
Control Number 22-AS-20240229081034
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: 07/14/2025
NARRATIVE
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On 02/19/2024, two caregivers saw R1 get up from the dining room chair, walk over to the dining room window and walk right into a chair which may have contributed to R1 banging their head on the window as they turned their head. One of the caregivers attempted to stop R1 prior to R1 walking into the chair. R1 was assessed by LVN; no bruises or marks were noted at the time. The LVN had applied an ice pack to prevent swelling. R1’s physician was notified and advised staff to keep an eye on the resident during their rounds. R1 did not complain of pain when they hit their head. On 02/24/2024, when R1 family visited, they noticed bruises on R1s forehead, they were told it was due to the incident that occurred on 02/19/2024, which they were not informed of.

R1s physician was notified about the bruises and bump on R1s forehead on 02/24/2024 and advised for R1 to be sent to the hospital for an evaluation. R1 did not suffer any internal injuries requiring medical treatment.
R1 was ambulatory during the time of their injury and the facility staff had acted appropriately during the incident on 02/05/2024 and on 02/19/2024, notifying the LVN and R1’s doctor. On 02/24/2024, when the bruises on R1s forehead became apparent, R1 doctor was notified immediately, and was sent out of the facility for medical evaluation.

Interviews with staff stated residents have the right to refuse to eat and the do not force any resident to eat. Based on the interviews it cannot be proved or disproved

Based on this interviews and records reviews, this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are unsubstantiated
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
02/29/2024 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 22-AS-20240229081034

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: 156DATE:
07/14/2025
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ephantus WaruiTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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.Facility staff failed to report incidents involving resident to responsible party
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted this unannounced complaint visit to deliver the results of the allegations above. The above allegations came in on 02/29/2024. The Department conducted an investigation into the allegations above.
A review of an incident report dated February 19, 2024 that was submitted by the facility to Community Care Licensing Division, does not have anything written down that the responsible party was notified of the incident. Administrator stated someone from the facility notified the responsible party right away, but the incident report does not state that. It does state the doctor was notified. The daily note also did not indicate responsible party was notified.
Based on the information gathered through interviews, LPA was able to determine that the allegation is substantiated. Therefore, the Department finds the allegation to be Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Please see 9099-D for the deficiency sited
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20240229081034
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: 07/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2025
Section Cited
CCR
87466
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Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes ...and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as... are observed, the licensee shall ensure that such changes are
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By 08/01/2025, Licensee shall submit a written plan of correction on how they shall ensure reporting requirements are followed and incident reports are complete.
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documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidence based on a review of documentation the responsible party was not notified which poses a possible health and safety risk to resident 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: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4