Beach Terrace Assisted Living And Memory Care

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff handled resident in a rough manner

Licensing Program Analyst (LPA) Jerome Haley arrived unannounced for the purpose of concluding the investigation and delivering the findings into the above allegation. LPA explained the reason for the visit to Executive Director (ED) Dennis Robeniol. During the course of the investigation conducted by LPA Sean Haddad on July 1, 2024, and on December 18, 2024, by LPA Jessica Cho, two resident and five staff interviews were obtained as well as the following pertinent documentation: Resident/Staff Roster, Staff Schedule, Written Statements, Resident’s Face Sheets, Physician’s Report, and Charting Notes. The investigation revealed the following: Regarding the allegation, Facility staff handled resident in a rough manner, it was alleged that on June 21, 2023, on or approximately 11:45pm, Resident #1 (R1) was “pulled and yanked” by their arm in an attempt to take R1 back to the second floor. Continued on LIC9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 24, 2024 · control 22-AS-20240624142605

Allegation investigated: Medication was not administered as prescribed.

Regarding the complaint allegation: Staff not administering medication as prescribed. During the investigation, 5 of 6 facility staff members confirmed the allegation above, and document review revealed information to support the allegation. A review of Resident 1’s (R1) charting notes reveal on November 23, 2024 and December 7, 2024 R1’s family was contacted about refilling R1’s medication. R1’s family was upset because specific instructions were given regarding refilling R1’s medications upon R1’s admission. Staff 4 confirmed R1 has missed medications, and confirmed R1’s family gave specific instructions regarding refilling the residents medications. Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report and appeal rights werethe state’s words, verbatim · CDSS document, Dec 24, 2024 · control 22-AS-20241205102328

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit regarding the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Regarding the complaint allegation: Staff handled resident in a rough manner. During the investigation, 6 of 6 staff members interviewed denied the allegation. According to Staff 4 (S$), the staff member has seen other staff members redirect resident 2 by grabbing the resident and talking to the resident like a child, but would not consider it being handled roughly. S4 says, the staffmembers grab R2 by the hands and says things like “hey, lets go.” Staff 3 (S3) had seen R2 redirected by other staff members, but denied ever seeing any of the staff members handle R2 in a rough manner. S3 simply stated, no. I haven’t seen that. Based on the information gathered the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, therthe state’s words, verbatim · CDSS document, Dec 24, 2024 · control 22-AS-20241205102328

Allegation investigated: Feces was left in the common area of the facility. Residents were not served or offered water with their meal/snack.

Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit regarding the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Regarding the complaint allegation: Feces was left in the common area of the facility. During the investigation, 7 of 8 individuals interviewed denied the complaint allegation. However, six staff members who were interviewed all confirmed a few residents in the Memory Care have been known to urinate in a corner or have a bowel movement in one of the common areas. The same staff members all went on to explain that housekeeping comes and cleans the areas and disinfects the areas right away. Staff 3 (S3) said the caregivers come in and clean it right away. Staff 5 (S5) confirmed a resident had a bowel movement by the elevator on the third floor. According to staff member, a housekeeper came and cleaned it right away. Staff 1 (S1) and Staff 2 (S2) both denied feces being left in any common area othe state’s words, verbatim · CDSS document, Dec 24, 2024 · control 22-AS-20241217175306

Allegation investigated: Resident sustained injuries while in care.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of concluding the investigation and delivering the findings into the above allegation. LPA met with Executive Director (ED Dennis Robeniol and explained the reason for the visit. During the course of the investigation conducted on November 14, 2024, and December 12, 2024, LPA conducted interviews with a total of two residents, five staff, and four individuals as well as obtained the Resident/Staff Rosters, Identification and Emergency Information, Physician’s Reports, Appraisals/Care Plans, Care Staff Assignments, Narrative Charting/Resident Assessments, Timecards, and other pertinent documentation. The investigation revealed the following: Regarding the allegation, Resident sustained injuries while in care, it was reported that on November 4, 2024, on or approximately 11:54pm, former roommates Resident #1 (R1) and Resident #2 (R2), were involved in a physical altercation resulting in R1 sustaining an injurthe state’s words, verbatim · CDSS document, Dec 18, 2024 · control 22-AS-20241106140703

Allegation investigated: Staff not administering medication as prescribed Facility staff provided falsified documents

Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of, interviews with facility staff, a resident, document review, and observation. Regarding the complaint allegation: Staff not administering medication as prescribed. During the investigation, 5 of 6 individuals acknowledged and/or confirmed resident medications have not been administered as prescribed. According to a staff member that was interviewed, med techs were pulled from the med cart for medication administration errors. During an interview with Staff 2, the staff member stated, I did have to pull one of them off the med cart and I was going to pull another one, but they resigned. They were combining 5:00pm and 8:00pm meds. Continued on LIC9099C Substantiatedthe state’s words, verbatim · CDSS document, Dec 12, 2024 · control 22-AS-20240909112643

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure call signal system is in good repair Staff do not respond to residents in a timely manner

An unannounced Complaint Investigation was conducted on this day regarding the allegations mentioned above by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Executive Director (ED) Dennis Rubeniol and explained the purpose of the visit. Interviews were conducted with four facility staff regarding the allegation staff do not ensure call signal system is in good repair. Two of four staff interviewed stated the pull cord located in memory care residents’ bathrooms does not signal or alert staff in any way and the facility does not have a call signal system; if a resident needs assistance they must yell out for help or wait for staff to come and check on them by happenstance. One of four staff stated there is no call system for memory care residents living on the third floor, however assisted living residents on the second floor of the facility have a call button, but the call system does not identify the specific resident living unit and the auditory signal does not produthe state’s words, verbatim · CDSS document, Nov 14, 2024 · control 22-AS-20241112141855

Allegation investigated: Facility used restraints on a resident Facility did not accord residents with dignity

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analysts (LPAs) Claudia Gutierrez and Samer Haddadin regarding the allegations mentioned above. LPAs met with Executive Director (ED) Dennis Robeniol and explained the purpose of the inspection. Interviews were conducted with five facility staff, and five residents, regarding the allegation facility used restraints on a resident. Five of five staff interviewed denied witnessing or having any knowledge of restraints being used on any resident. Four of five residents interviewed denied facility uses restraints on them and denied witnessing or having any knowledge of restraints being used on any other resident. One of five residents was unable to confirm or deny the allegation. Interviews were conducted with five facility staff, and five residents, regarding allegation facility did not accord residents with dignity. Per Reporting Party (RP), residents are not accorded with dignity as they are forcefullythe state’s words, verbatim · CDSS document, Nov 5, 2024 · control 22-AS-20241030120215

Allegation investigated: Facility staff failed to provide records.

Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Regarding the complaint allegation: Facility staff failed to provide records. During the investigation it was discovered a document was requested by the responsible party and Power of Attorney (POA) for Resident 1 (R1). During an interview with staff, it was confirmed a record request was made verbally on Monday, October 28, 2024. Staff explained to the individual making the request, they would need to submit a record request in writing. Document review reveals a request was made via email the same day, and the individual making the request was denied access to the record(s) for R1. Continued on LIC9099C Substantiatedthe state’s words, verbatim · CDSS document, Oct 30, 2024 · control 22-AS-20241029184225

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility admitted resident without legal consent.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to complete and close the investigation regarding the complaint allegation above. LPA was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of interviews and document review. Regarding the complaint allegation: Facility admitted resident without legal consent. During the investigation document review revealed Resident 1’s (R1) admission agreement was signed and dated on June 9, 2023 by R1’s Power of Attorney (POA). A review of the signed California General Durable Power of Attorney agreement was signed by R1 and R1's POA on May 6, 2023. The agreement states the following: TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF (N) AND IGNORE THE LINES IN FRONT OF THE OTHER POWERS. Continued on LIC9099C Unfoundedthe state’s words, verbatim · CDSS document, Oct 9, 2024 · control 22-AS-20231128104857

Allegation investigated: Staff improperly destroyed medication, including narcotics.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit regarding a complaint that was filed June 4, 2024. During the investigation, interviews were conducted, and documents were reviewed. Regarding the allegation: Staff improperly destroyed medication, including narcotics. 4 of 6 staff interviewed were able provide information on the medication destruction process. According to Staff 2 (S2), Staff 5 (S5), and Staff 6 (S6), medication is destroyed during the NOC (overnight) shift. According to S2, depending on what shift received an order, the medication will be placed in a bin and the NOC shift will destroy the medication. S6 says, they believe medication is being destroyed on the NOC shift because they have more down time. Document review revealed, medication has been destroyed by several different individuals and some medication destruction records did not have any signature on the medication destruction record. Continued on LIC9099C Substantiatedthe state’s words, verbatim · CDSS document, Jun 10, 2024 · control 22-AS-20240604120144

Allegation investigated: Staff hit a resident

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit regarding a complaint that was filed June 4, 2024. During the investigation, interviews were conducted, and documents were reviewed. Regarding the allegation: Staff hit a resident. 7 of 7 individuals interviewed denied having knowledge of the complaint allegation above. Staff 2 (S2), Staff 3 (S3), and Staff 5 (S5) all said they were not aware of any staff hitting a resident. Staff 1 (S1) denied the allegation and revealed the hitting of a resident would prompt an investigation and immediate termination. Based on the information gathered during the investigation through interviews, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report wasthe state’s words, verbatim · CDSS document, Jun 10, 2024 · control 22-AS-20240604120144

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: The facility does not have insurance coverage.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to start the investigation for a complaint received February 27, 2024. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: The facility does not have insurance coverage. After a brief discussion with Executive Director Eric Jensen, it was discovered the facility has a valid insurance policy. The insurance policy was provided and reviewed during the visit. Upon review, it was discovered the insurance policy is current and meets regulation requirements. Based on the information gathered through interview and document review, the following allegation: The facility does not have insurance coverage, is deemed unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Feb 28, 2024 · control 22-AS-20240227112730

Allegation investigated: A lack of supervision resulted in a resident being assaulted by other residents while in care. Staff are not properly reporting all incidents. Staffing is insufficient in quantity to meet residents needs.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver the findings on the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit. The complaint investigation consisted of a review of incident reports, facility notes, interviews with facility residents, facility staff, family members, witnesses, and observations. Regarding the allegation: A lack of supervision resulted in a resident being assaulted by other residents while in care. 0 of 11 individuals could provide evidence to support the complaint allegation. During the investigation it was discovered that Resident 1 (R1) was involved in altercations with other residents. According to facility staff, when residents are involved in an altercation, the residents are separated, isolated, and the family and physicians are notified. Continued on LIC9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2024 · control 22-AS-20231016115710

Allegation investigated: A resident was assaulted by another resident due to a lack of supervision

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit. The complaint investigation consisted of a review of interviews with facility staff, resident family members, witnesses, and document review. Regarding the allegation: A resident was assaulted by another resident due to a lack of supervision. 0 of 8 individuals were able to provide any evidence to support the allegation. During the investigation it was determined Resident 1 (R1) had multiple encounters with Resident 2 (R2). Multiple staff members confirmed R1 and R2 did have an encounter in the dining room. Document review revealed there were encounters between R1 and R2 on the dates of October 12, 2023, October 14, 2023, and October 17, 2023. Continued on LIC9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2024 · control 22-AS-20231018094417

Allegation investigated: Staff do not provide activities for the residents Staff did not provide resident with linen

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegations above. LPA Haley was granted entry and explained the reason for the visit with upon entry. During the visit LPA Haley conducted interviews with four residents, and 1 additional staff member Staff 5 (S5) to gather additional information. Regarding the allegations above, during the investigation 6 of 7 staff members confirmed activities are scheduled throughout the day and activities start around 9:30AM after breakfast. According to Staff 3 (S3) one activity residents play is Senior Volleyball with a balloon. During an interview with Staff 2 (S2) who was the activity’s coordinator at the time explained, residents participate in various activities like stretching, coloring, cornhole, bowling, and a laundry activity. LPA Haley was provided a copy of the activities calendar for various months. During interviews it was discovered residents can also sing and dance if they like. While visitithe state’s words, verbatim · CDSS document, Dec 13, 2023 · control 22-AS-20221228161711

Allegation investigated: Staff did not provide resident with a comfortable bed

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegation above. LPA Haley was granted entry and explained the reason for the visit with upon entry. During the visit LPA Haley conducted interviews with four residents, and 1 additional staff member Staff 5 (S5) to gather additional information. Regarding the allegations: Staff did not provide resident with a comfortable bed During the investigation it was discovered a resident was observed laying directly on the springs of his bed. LPA Haley was provided a photo of the resident laying directly on the bed frame with no mattress or sheets. There was a blue blanket laying on top of the resident and that was the only linen observed in the photo. In the photo you could see the resident’s mattress propped up against the wall. It is unclear why the resident was laying on the bed frame without a mattress or linen. An individual provided the photo on January 19, 2023 at 4:30 PM. The individual did notthe state’s words, verbatim · CDSS document, Dec 13, 2023 · control 22-AS-20221228161711

Allegation investigated: Staff do not meet residents' incontinence needs Staff do not meet residents' grooming needs

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegations above. LPA Haley was granted entry and explained the reason for the visit with upon entry. During the visit LPA Haley conducted interviews with four residents, and 1 additional staff member Staff 5 (S5) to gather additional information. Regarding the allegations above, during the investigation 6 of 7 staff members denied both allegations. Regarding incontinence needs, staff members interviewed claimed caregivers check resident’s every two hours. Staff 3 (S3) claims residents are checked and if they’re wet, they’re changed. Even when the resident is aggressive with the staff, back up staff will be called to assist the caregiver so the resident can be changed. According the S5, caregivers check the residents every two hours and it’s documented on the “Quick Mar” system. All the residents are available on the Quick Mar. Incontinence care, grooming, and activities are tracked for each rethe state’s words, verbatim · CDSS document, Dec 13, 2023 · control 22-AS-20221228161711

Allegation investigated: Staff made resident lie on floor for discipline Staff did not respond to a resident's needs timely Staff speak inappropriately to residents in care

LPA Haley made an unannounced visit to deliver the findings on the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Staff made resident lie on floor for discipline. During the investigation interviews were conducted with facility staff, family members of Resident 1 (R1), and hospice employees. 5 staff members acknowledged R1 was placed on the floor, but denied it was for discipline. Staff 1 (S1) stated R1 is a fall risk and has asked to be placed on the floor, so the resident doesn’t fall. Staff 5 (S5) says R1 gets agitated and will request to be placed on the floor, and said R1’s family, the son, and hospice are aware and it’s in the care plan. 2 members of R1’s family and 2 hospice employees denied seeing R1 on the floor. However, both family members and both hospice employees denied R1 could requested to sit on the floor. Continued on LIC9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 16, 2023 · control 22-AS-20230306125953

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Lack of supervision resulted in resident falling and sustaining an injury.

LPA Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Lack of supervision resulted in resident falling and sustaining an injury. The investigation into the complaint allegation above revealed, on August 23, 2023 around 7:00PM Resident 1 (R1) suffered an unwitnessed fall near the caregiver break room on the third floor of the facility. R1 was sent to West Anaheim Medical Center for pain to the head due to the fall. R1 was then transferred to Kaiser Anaheim for a higher level of care. At Kaiser Anaheim, R1 was treated for a cervical (neck) vertebral fracture due to the fall and ordered to stay in the cervical collar for the next three months. 8 of 9 witness confirmed R1 had an unwitnessed fall on August 23, 2023, and returned to the community with a neck brace. Continued on LIC9099C Substantiatedthe state’s words, verbatim · CDSS document, Oct 25, 2023 · control 22-AS-20230825151110

Allegation investigated: Facility plumbing is not providing hot water

LPA Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Facility plumbing is not providing hot water 8 of 8 witnesses confirmed the complaint allegation to be true. The investigation into the complaint allegation above revealed, on August 22, 2023 information was shared with the Executive Director (ED) Eric Jensen that there was water leaking from the hydro pump that provides hot water to the building. The next day on August 23, 2023 more water was observed leaking from the pump but there was still hot water in the building. On August 24, 2023 it was discovered the hydro pump was no longer working and there was no hot water in the building. While the facility worked on a solution to make necessary repairs, the residents went without hot water from August 24, 2023 until September 9, 2023. Substantiatedthe state’s words, verbatim · CDSS document, Oct 25, 2023 · control 22-AS-20230907130523

Allegation investigated: Staff did not prevent residents from wandering away from facility.

LPA Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Staff did not prevent residents from wandering away from facility. During the investigation it was discovered that residents have made it to the first floor of the facility, but never exited the building. There have been times family members and vendors using the elevator, politely hold the elevator door for people, not knowing the person they held the elevator door open for is a resident of the facility. When the resident makes it down to the first floor, the receptionist will redirect the resident and call a caregiver to take the resident back to the third floor. No resident has successfully made it out of the building after taking the elevator to the first floor. It was discovered in a separate incident, one of the residents was able to make it to the building’s fire escape/balcthe state’s words, verbatim · CDSS document, Oct 25, 2023 · control 22-AS-20230907130523