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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006746
Report Date: 04/07/2026
Date Signed: 04/07/2026 05:49:03 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
03/30/2026 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260330160253
FACILITY NAME:BEACH TERRACE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306006746
ADMINISTRATOR:CHON,CHRISTINEFACILITY TYPE:
740
ADDRESS:12282 BEACH BLVDTELEPHONE:
(714) 694-3205
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 64DATE:
04/07/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:John YoonTIME COMPLETED:
06:05 PM
ALLEGATION(S):
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9
Resident's dietary restrictions were not followed
Insufficient staff to meet resident's needs
Responsible party was not notified of resident's change in condition
INVESTIGATION FINDINGS:
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An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Operations Director John Yoon and explained the purpose of the inspection.

Regarding the allegation, Resident's dietary restrictions were not followed, the following was revealed: It is alleged Resident 1’s (R1’s) dietary restrictions were not followed despite dietary restrictions being given to Administrator (AD) at the time R1 was admitted. During their interview, R1 denied having any dietary restrictions or being on a special diet. Per R1’s Pre-Placement Appraisal (LIC603) dated November 21, 2024, R1 does not eat pork or pork by products and per their Physician Report (LIC602) dated January 20, 2026, R1 is on a special diet consisting of No-Added-Salt (NAS) and regular texture. During their interview, Staff 4 (S4) confirmed allegation and stated R1’s dietary restriction was not followed on at least one occasion. Per S4, on Wednesday, April 1, 2026, R1 was accidentally served pork after staff grabbed the wrong plate and served it to R1. (Cont. LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
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 7
Control Number 22-AS-20260330160253
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: BEACH TERRACE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306006746
VISIT DATE: 04/07/2026
NARRATIVE
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During their interview, Witness 1 (W1) corroborated the allegation and stated they had been present at the time R1 was served with pork and provided LPA with a picture of R1’s plate from that date, consisting of pull pork, mixed vegetables, and mashed potatoes.

Regarding the allegation, Insufficient staff to meet resident's needs, the following was revealed: It is alleged that on March 23, 2026, R1 was being changed by Staff 1 (S1), and S1 alone, however, R1 requires a two person assist for diaper changes. During their interview, R1 was unable to confirm or deny allegation. During their interview, S1 corroborated the allegation and stated they were aware R1 required a two person assist, however, assisted R1 with incontinence care alone, as no other care staff was available. Per W1, they had been present at the time and they had to assist S1, as no other care staff was available to assist.

Regarding the allegation, Responsible party was not notified of resident's change in condition, the following was revealed: It is alleged R1’s responsible party was not notified of R1’s bed sores. During their interview, R1 was unable to confirm or deny allegation. During their interview, W1 stated that on March 23, 2026, they discovered bed sores on R1, and facility staff had not notified them. During their interview, Staff 2 (S2) corroborated the allegation and stated it had been W1, who informed them of R1’s bed sore. Per Staff 3 (S3) they had notified R1’s responsible party and provided LPA with an email and phone call notification, however, email and phone call were not placed until April 3, 2026.

Based on staff and witness interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Deficiency are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided at the end today's inspection.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
03/30/2026 and conducted by Evaluator Claudia Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260330160253

FACILITY NAME:BEACH TERRACE ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
306006746
ADMINISTRATOR:CHON,CHRISTINEFACILITY TYPE:
740
ADDRESS:12282 BEACH BLVDTELEPHONE:
(714) 694-3205
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 64DATE:
04/07/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:John YoonTIME COMPLETED:
06:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's needs were not met
Resident was not accorded sufficient space in their accommodation
Staff left resident in unhygienic conditions
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Operations Director John Yoon and explained the purpose of the inspection.

Regarding the allegation, Resident's needs were not met, the following was revealed: It is alleged R1 has a health condition that requires them to wear compression socks and, on several occasions, R1 has not had their compression socks on. It is also alleged R1’s bed rails are not being used at nighttime which led to a fall from bed recently. During their interview, R1 was unable to confirm or deny whether or not they required or wear compression socks or if their bed rail was not being used. During their interview, three of three stated they did not have a doctor’s order for R1 requiring compression socks, however, stated R1’s family members had stated R1 had a medical condition which required compression socks. Per three of three staff, R1’s bedrails are used, and they denied having any knowledge of R1’s bedrails being left in a downward position overnight. (Cont. LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
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 7
Control Number 22-AS-20260330160253
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: BEACH TERRACE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306006746
VISIT DATE: 04/07/2026
NARRATIVE
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During the course of the investigation, LPA obtained a copy of Internal Occurrence Report and interviewed R1’s family members, Witness (W1) and Witness 2 (W2). Per Internal Occurrence Report (IOR), R1 was found on the floor in their bedroom on March 26, 2026 at 5:30 a.m. IOR does not indicate whether or not the bed rails were in place at the time of the fall. Per Staff 2 (S2), however, the bedrails were in place. During their interview, R1’s family member, W1 stated they did not have a doctor’s order for compression socks and stated one may have been provided to R1 some time ago but was unsure if R1 had a current doctor’s order. Per W1, R1 did have a fall from bed recently and facility staff were unable to confirm if the bedrails had been in place during the night. During their interview, W2 also stated they were unsure if a doctor’s order for compression socks had been obtained and stated W1 had a background in healthcare and may have believed it was best that R1 wear compression socks. W2 denied having any knowledge of whether or not R1’s bedrails were being used.

Regarding the allegation, Resident was not accorded sufficient space in their accommodation, the following was revealed: It is alleged R1’s bed is pushed to the side and the room is not shared equally as R1’s roommate has more space for their belongings. During their interview, R1 was unable to confirm or deny whether or not they are accorded sufficient space in their accommodation. During their interview, R1’s roommate, R2 denied the allegation and stated the bedroom space is divided evenly and both they and R1 are able to move about the room comfortably with their wheelchairs. Two of four additional residents interviewed, denied the allegation and stated they are accorded sufficient space in their bedroom accommodation. Two of four residents were unable to confirm or deny the allegation. During their interview, three of three staff denied pushing or moving R1’s furniture aside, and stated that resident bedrooms are divided evenly, and there is no preference for one resident’s space or accommodation over the other.

Regarding the allegation, Staff left resident in unhygienic conditions, the following was revealed: It is alleged that during a diaper change, Staff 1 (S1) did not remove their gloves when placing the new diaper and smeared feces onto R1’s clothing. During their interview, R1 was unable to confirm or deny whether or not they had been left in unhygienic conditions. During their interview, S1 stated they only assisted R1 with a diaper change on one occasion, however, denied wearing soiled gloves or smearing feces on R1. Per S1, their gloves were clean, and it is facility protocol to remove their gloves after assisting a resident with incontinence care. Interviews were conducted with five additional facility residents and two staff. One of five residents was unable to confirm or deny allegation and four of five residents denied being left in unhygienic conditions by staff. (Cont. LIC9099-C)
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20260330160253
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: BEACH TERRACE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306006746
VISIT DATE: 04/07/2026
NARRATIVE
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Two of two staff denied having any knowledge of R1 or any other resident being provided with incontinence care by a staff member with soil gloves and stated it is facility protocol to wear clean gloves and to remove their gloves after assisting a resident with incontinence care.

Due to conflicting information received during interviews conducted, LPA is unable to determine if Resident's needs were not met, if Resident was not accorded sufficient space in their accommodation, or if Staff left resident in unhygienic conditions. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore at this time the above allegations are unsubstantiated.

An exit interview was conducted and copy of this report was provided at the end of the inspection.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 22-AS-20260330160253
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: BEACH TERRACE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306006746
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2026
Section Cited
CCR
87464(d)
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(d)... the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal...

This requirement is not met as evidenced by:
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S4 immediately updated culinary board to include R1's dietary restictions and OD stated staff training will be conducted and a copy provided to LPA via email by POC date.
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Based on staff interview, the Licensee did not comply with the section cited above as R1's needs as identifed in their Pre-Placement Appraisal were not met, which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
04/08/2026
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...

This requirement is not met as evidenced by:
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OD stated staff schedule will be updated to ensure two care staff are avaialbe to assist R1 and staff training will be conducted and a copy provided to LPA via email.
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Based on staff interview, the Licensee did not comply with the section cited above as one staff assisted R1 alone due to no other care staff being available, despite R1 requiring a two person assist for diaper changes, which poses an immediate safety and personal rights 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20260330160253
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: BEACH TERRACE ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 306006746
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2026
Section Cited
CCR
87211(a)(1)(D)
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(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of... (D) Any incident which threatens the welfare, safety or health of any resident..

This requirement is not met as evidenced by:
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OD stated staff training will be conducted to ensure residents' responsible parties are notified of any incident which threatens the welfare, safety or health of any resident and a copy provided to LPA via email.
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Based on staff interview and record review, the Licensee did not compy with the section cited above as R1's responsible party was not notified R1 had developed bed sores, which poses an immediate health, safety, and personal rights 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: Lourdes Montoya
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7