Beach Terrace Assisted Living and Memor

Type of visit: Case Management - Other

LPA Haley arrived at the facility to deliver findings on complaint control number 22-AS-20250923151212 and conduct a case management visit under the old facility number 306005901. Findings for the complaint were delivered successfully, and the complaint is now closed. No additional action is required. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 16, 2026

Allegation investigated: 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

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 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. 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) 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.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 22-AS-20260330160253

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Apr 8, 2026

(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: 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.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 8, 2026

(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: 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.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 8, 2026

(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: 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.the state’s words, verbatim · CDSS document, Apr 7, 2026

Plan of correction: 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.

Type of visit: Prelicensing

Licensing Program Analysts (LPA) Jerome Haley made a follow up pre-licensing visit to ensure the required correction has been completed. LPA arrived and explained the purpose of the visit to staff. During the follow up inspection, LPA Haley check the hot water temperature in resident bedrooms on all three wings of both floors. During the inspection, hot water temperature was measured between 105.6 – 108.1 degrees F. There are no additional corrections needed. The facility is ready for licensure. Component III: was waived during the follow up visit as Executive Director Christine Chon has extensive experience and has been through the pre-licensing process at previous facilities. An exit interview was conducted and a copy of this report, was provided to Executive Director Christine Chon.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Prelicensing

Licensing Program Analysts (LPA) Jerome Haley made an announced visit for the purpose of conducting a pre-licensing evaluation. LPA Haley was greeted and granted entry by Executive Director Christine Chon. Initial application: To operate a Residential Care Facility Elderly/Dementia (RCFE), with a capacity of 120, of which 120 may be bedridden and waiver granted for Hospice (20) was submitted to the department for licensure. Fire clearance: Orange County Fire Authority granted the Fire Clearance May 13, 2025. Structure: The facility is a three-level structure with a total of 66 bedrooms for residents in care. All resident rooms are on the second and third floor. Assisted Living (AL) residents are located on the second floor and Memory Care (MC) residents are on the third floor. Bedrooms: All bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Non-skid surface and grab bars were observed. Two public bathrooms are located on each floor. Kitchen: The kitchen is clean, well organized and remains locked and inaccessible to residents. Sharps are located in a drawer. LPA observed a large commercial oven that was being used, a commercial refrigerator/freezer. LPA observed an emergency supply of food and water. The main kitchen is on the first floor, and there are two smaller kitchens, one on the second floor and one on the third floor. During meal times the food is brought over from the main kitchen to one of the smaller kitchen areas to be served to the residents on that floor. Food Service: Food deliveries are made twice a week by Cisco. During the inspection LPA observed a perishable and nonperishable food supply that meets regulation requirements. Continued on LIC809C page: 1 of 3 Garage/Parking Area: A covered parking structure is available for staff and authorized visitors when there is no more visitor parking is available. Visitor parking is available in front of the building. Toxins: All toxic chemicals, soaps, detergents, and cleaning solutions were observed in locked rooms (kitchen, laundry room) and inaccessible to residents in care. Client & Staff Files: Staff and resident files are stored on the first floor in the business office. Medications/First-Aid Kit: The med room is located on the third floor. The med room remains locked and inside the locked med room, LPA observed three medication carts, incontinent supplies and resident’s medical files. LPA observed three first aid kits that meet regulation requirements. One first aid kit on each floor. Linens & Hygiene Supplies: Hygiene items were observed in resident bathrooms, and the facility keeps a supply of clean linens to use as back up and in case of emergency. Exterior: Residents have access to two outside areas located on the second floor. Outside walkways are clear and free of obstruction. Table with sunshade and chairs were observed. No bodies of water observed. Laundry: There are two laundry rooms available. One on the second floor and one on the third floor. Residents are on a laundry schedule, but the AL residents can use the laundry room as needed. Smoke/Carbon Monoxide Detectors: Sprinkler and fires systema check are checked by AV Com and are inspected quarterly. Fire Extinguisher: Multiple Fire extinguishers were observed mounted on the walls throughout the facility. Emergency Phone Numbers, House Rules, Exit Plan & Menu: Facility postings were observed in the front lobby on the front desk and on the desk right behind the reception desk. Continued on LIC812C page: 2 of 3 Additional Comments: The facility telephone number is: 714.694.3205, the secondary number is 657.724.9844, and the facility email address is 14730enterprise@gmail.com and was confirmed during the visit. Activities items were observed including arts and crafts items, and musical entertainment for the residents to enjoy. Component III: Component III was not presented as the facility has one correction to make. A follow up visit will be scheduled. Corrections Needed: · Hot water temperature – Hot water needs to be slightly adjusted to meet regulation guidelines. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2025