Beach Terrace Assisted Living and Memory Care.
Beach Terrace Assisted Living and Memory Care is Ranked in the bottom 3% of California memory care with 28 CDSS citations on record; last inspected Apr 2026.
A large home, reviewed on public record.
Compared to 94 California facilities with a similar number of beds.
RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · FREE
Beach Terrace Assisted Living and Memory Care has 28 citations on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
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Citation history, plotted month by month.
28 deficiencies on record. Each bar is a month with a citation.
Finding distribution
28 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Elopements, fires, epidemic outbreaks, and poisonings must be reported immediately. Abuse with serious bodily injury requires a 2-hour phone report + 2-hour written report to CDSS, Adult Protective Services, and law enforcement. Abuse without serious bodily injury must be reported within 24 hours. A resident death requires a phone call by the next working day and a written report within 7 days. Injuries requiring medical treatment beyond first aid, and bankruptcy/foreclosure/utility shutoff notices, must also be reported. Incidents not reported on time are a separate violation — families may file a complaint directly with CDSS.
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“When was the last incident report filed with CDSS, and may I see your incident log summary for the past 12 months?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Beach Terrace Assisted Living and Memory Care's record and state requirements.
The facility has 16 serious citations on file across all inspections — can you provide your corrective-action plan for each cited item, and show families any documentation of remediation steps taken?
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42 complaints are on file with CDSS — were any substantiated, and what remediation did the facility take in response to substantiated findings?
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The most recent inspection occurred on April 3, 2026 — can you provide the deficiency notice from that visit and walk families through any corrective actions completed since then?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
35 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-04-14Complaint InvestigationUnsubstantiatedNo findings
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Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, facility staff does not ensure facility bedrooms are in good clean condition, revealed the following. It was reported that Resident 1's (R1) bedroom was not kept clean. It was reported that R1's bathroom was not cleaned regularly. W1 reported that when they visit R1 their room was not clean and the bathroom was always dirty. W1 reported that sometimes R1's bathroom smelled like urine. No dates and times were provided. R1 moved into the facility on May 20, 2024 and moved out of the facility on January 29, 2025. R1 had been diagnosed with Dementia and resided in the memory care area of the facility. 4 out of 4 caregivers interviewed reported that R1 was reluctant to accept help with toileting so it was challenging to assist R1 but they did everything they could to assist and they always provided assistance to R1. 2 out of 2 housekeeping staff reported that when ever R1's bathroom needed to be cleaned they cleaned it. Both housekeeping staff denied the allegation and reported R1's room required extra cleaning because of their behaviors but they kept R1's room clean. During the initial 10-day visit LPA and staff toured R1's room which had already been vacated and no deficiencies or issues were observed. LPA observed the room was clean. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, facility staff handled resident in a rough manner, revealed the following. It was reported that the Activities Director grabbed R1 causing R1 to suffer cuts on their arm. Photographic evidence provided shows R1 had 3 cuts on their upper left arm. The Activities Director denied the allegation and reported they have never put their hands on any resident. W1 reported that the Activities Director grabbed R1 which caused the injuries. W1 reported that they did not witness the incident. 5 out of 5 staff reported they were working in memory care on the day R1's injuries were discovered and didn't witness anything that could have caused the injuries. The Memory Care Director reported that on the day R1 was found to have cuts on their arm there were no incidents during the activity led by the Activities Director involving R1 or any resident. The Memory Care Director reported that they have never witnessed any type of abuse by any staff member to any resident. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The Administrator at the time the complaint was filed, Dennis Robeniol, reported that they spoke to the family of R1 and interviewed staff (5 staff members working in memory care) and no one witnessed any incident involving R1 or the Activities Director that could explain the injuries on R1's arm. Staff reported they applied first aid to R1 and there was no report of pain. LPA attempted to interview 3 residents who participated in the activity but none of the residents responded to the LPA's questions. It is unclear what caused R1's injuries. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, facility staff are not properly assisting resident with daily dressing, revealed the following. It was reported that R1 is not properly dressed in the morning and goes around the facility with no shoes or mismatched shoes. 4 out of 4 caregivers reported that R1 is always assisted with dressing in the morning. 4 out of 4 caregivers reported that R1 has frequently taken off their shoes or slippers and has left them throughout the facility, but staff always redirect R1 and make sure they are wearing shoes or slippers. The Memory Care Director reported that all memory care staff are aware of R1 removing their shoes and slippers and leaving them in different places so it is not an issue because staff have been informed and trained to immediately assist R1 with their shoes or slippers. W1 reported that on 2 different occasions (no dates provided) they went to visit R1 and one time they had no shoes on and the other time they had mismatched shoes on. The Memory Care Director reported that on one occasion (they don't remember the date) they were informed by a visitor that R1 had no shoes on and R1's shoes were found down the hall and they were assisted immediately. The Memory Care Director reported that R1 took off their shoes and then their visitor arrived and saw them with no shoes and R1 was immediately assisted by staff. W1 reported that during this incident they assisted R1 and no staff were present. W1 did not recall the day of the incident. The Memory Care Director reported that they weren't aware of R1 putting on 2 different shoes and no one reported any such incidents. 4 out of 4 caregivers interviewed reported that they were unaware of R1 wearing mismatched shoes and had only observed R1 removing their shoes or coming out of their room with no shoes on. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The investigation into the allegation, facility staff are not meeting residents toileting needs, revealed the following. It was reported that R1 was not assisted with their incontinence needs and the facility staff asked the family to provide special clothing, like "onesies" or jumpsuits to aid with removing clothing because of the incontinence issues. The Administrator and Memory Care Director denied the allegation and reported that they have never recommended any type of clothing for any resident. 4 out of 4 caregivers reported that R1 requires assistance with toileting but is reluctant to accept help but they still assist. 4 out of 4 caregivers reported that R1 has no issue going to the bathroom but sometimes they miss the toilet. 4 out of 4 caregivers reported that sometimes R1 doesn't make it to the toilet so they assist in changing R1. All 4 caregivers reported that R1 is a challenge but they denied the allegation and reported R1 is never left in soiled clothing and is always assisted. W1 reported they have never been present when R1 has had any toileting issues. 2 out of 2 Medication-Technicians (Med-Techs) who work in Memory Care reported they have never witnessed R1 being left in soiled clothing. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
2026-04-03Other VisitNo findings
2026-04-03Complaint InvestigationUnsubstantiatedNo findings
2025-07-14Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint was investigated about supervision of a resident who had several incidents involving leaving or attempting to leave the facility shortly after moving in. The facility documented that staff were instructed to watch the resident and updated the resident's care plan after admission, though the inspector could not determine whether the supervision plan fully met the resident's needs. The complaint was not substantiated.
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This incident occurred shortly after the resident moved in. There were notes that the staff were instructed to be aware of the resident’s whereabouts and a possible one-one-one, but did not specify how long that was going to last. It cannot be determined if R1 was an elopement risk prior to moving into the facility because it cannot be determined if the resident had exit seeking behaviors prior to the first incident and the second two incidents the resident didn’t leave the facility grounds. 2. Title 22 regulations at the time required appraisals and needs/services plans to be updated when there was a change in condition or every twelve months, whichever came first. However, the regulations do not specify how much detail is required for each appraisal and needs/service plan to be. A review or R1’s file showed the resident’s needs and services plan was updated at least once after the resident moved in. Supervision was addressed, but because the regulations don’t specify how detailed the plan is supposed to be, it cannot be determined whether the appraisal met the resident’s needs or not. Therefore, LPA finds the allegation to be "unsubstantiated." A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the violation occurred.
2025-07-11Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint investigation looked into allegations about a resident's fall, nutrition and hydration, pressure injury, and access to medical records. The facility could not be found to have violated regulations because staff records showed the resident was able to walk independently, the resident refused food and drink which staff cannot force, turning logs are not required by law, and the facility's record-access procedures could not be fully reviewed. No violations were substantiated.
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Because the facility records and staff interviews indicate the resident was able to walk without assistance, it cannot be determined if the fall was a result of staff neglect. 2. & 3. Interviews with staff and witnesses stated the resident started to decline quickly and refused to eat and drink. Staff are not allowed to force a resident to eat and drink. Witnesses stated the resident was declining and observed food and liquids in the resident’s room. Other interviews stated staff did not take the time to ensure resident ate all that the resident wanted to eat. The department cannot prove or disprove the resident became severely dehydrated and malnourished due to staff neglect. 4. A review of the records showed the resident started hospice care with one hospice agency and ended with another one. The resident had a fall that resulted in the resident becoming bedridden and required to be turned every two hours. The change in condition was noted in the resident’s hospice care plans but a log was not completed by staff. A log is not required per Title 22 regulations. Interviews also stated the resident declined quickly and was in poor health. Because logs to keep record of when a resident is turned per the care plan is not required and the resident’s health condition it cannot be determined if the resident developed an unstageable pressure injury due to neglect. 5. Per Title 22 regulations, resident records shall be made available to a person designated with the written consent of the resident. LPA was unable to review the resident's record. LPA was unable to determine what records were requested by the resident's responsible party. Therefore, LPA finds the allegation to be "unsubstantiated." A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the violation occurred.
2025-07-10Annual Compliance VisitNo findings
Plain-language summary
This was an unannounced annual inspection on April 27, 2026. The inspector toured the facility and found it well-maintained with appropriate safety features including grab bars, nonskid shower flooring, and emergency exits on each floor; one of two elevators was temporarily out of service but the facility had immediately placed a repair work order and the director confirmed staff were reviewing emergency procedures during that time. No violations were found.
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Licensing Program Analyst (LPA) Hiratsuka, conducted this unannounced annual visit. LPA toured the facility with Executive Director Christine Chon. This facility changed management company on April 16, 2025. This facility has a fire clearance for one hundred and twenty who all may be bedridden. This facility has three floors: the first floor has offices and is the main entrance. There are two elevators in the facility. The residents are on the second and third floor. The second floor has two outdoor terraces. There are emergency exits for each floor. There is also an elevator for the kitchen. There is a dining room on each floor and common areas. LPA toured several rooms at random on each floor. There are several rooms on each floor that share a hallway and a full bathroom. The rest of the resident rooms have their own private full bathrooms. There are common half bathrooms on each floor. All bathrooms have grab bars and the showers have nonskid flooring. Each room has required furniture. During this visit LPA observed one of the two main elevators not working. LPA was informed the work order was put in the day it occurred and they are waiting for the schedule of the technician from the company to repair the elevator. There are no deficiencies cited because the issue was addressed as soon as it occurred. Executive Director stated she is making sure staff are reviewing emergency procedures while one elevator is not working. Multiple topics discussed. No deficiencies cited.
2025-07-10Complaint InvestigationNo findings
Plain-language summary
A complaint alleged a problem with the resident's personal belongings, but the investigation found no violation. The resident's responsible party declined to have the facility conduct a formal inventory of belongings when the resident moved in, so the complaint could not be substantiated.
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The department conducted interviews and reviewed the resident’s file. The resident’s personal property and valuables list in the admission agreement declined a formal inventory of their belongings upon move-in. Because the personal belongings inventory by the facility was declined by the responsible party upon move-in, the allegation is unfounded. Based on the evidence gathered, the Department finds that the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
2025-06-03Annual Compliance VisitType A · 2 findings
Plain-language summary
On November 9, 2024, a resident became suspended by the neck from a bed rail, and staff called another staff member instead of immediately calling 911, resulting in a delay of approximately 30 minutes before paramedics arrived and provided care. An unannounced inspection found that staff training records were not on file for two employees, though those employees did have current CPR and First Aid certifications. No violations were found related to facility cleanliness.
“Based on interviews and record review, three out of the three staff confirmed not providing rescue measures and placing an immediate 911 call when R1’s health and safety was in imminent danger which poses an immediate Health or Safety risk to persons in care.”
“Based on interviews and record review, facility did not maintain annual/intial training records for S1 and S3 which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.”
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Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced Case-Management-Deficiencies visit and met with Executive Director (ED) Christine Chon. During the investigation of Complaint Control #22-AS-20241112125326, the following deficiencies were discovered: The investigation revealed that the staff failed to administer first aid to Resident #1 (R1) who was suspended by the neck from the bed rail on November 9, 2024. Staff #1 (S1) called Staff #2 (S2) instead of immediately placing a 911 call after discovering R1 resulting in R1 to wait approximately 30 minutes until aide was provided by the paramedics. During today's inspection, no ants were observed in the six apartment units, and no current training records were on file for S1 and Staff #3 (S3). LPA verified that S1-S3 had a current and valid CPR/First Aid certificate. Deficiencies are being cited as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-Ds. An exit interview was conducted with Executive Director Christine Chon, and a copy of this report including the LIC809Ds, LIC811s, and the appeal rights were provided at the end of the visit.
2025-06-03Complaint InvestigationSubstantiatedType A · 2 findings
Plain-language summary
A complaint investigation found that a resident with advanced dementia and hospice care fell during the night and became suspended by the neck from a bed rail; staff failed to conduct required two-hour check-ins, did not call 911 promptly when discovered, and the resident remained trapped for approximately 30 minutes while covered in live ants, resulting in respiratory failure and low oxygen levels. The investigation also confirmed the facility had a pest infestation, with ants observed throughout multiple resident rooms. The state substantiated both the neglect allegation and the pest infestation complaint and assessed civil penalties.
“Based on the Department’s interviews and record review, facility staff did not conduct routine checks and provide immediate rescue measures at the time R1 was discovered which poses an immediate Health and Safety risk to persons in care.”
“Based on observation, interviews, and record review, three witness staff and medical responders witnessed the ants covering R1’s mouth, face, and body which poses a potential Health and Safety risk to persons in care.”
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Regarding the allegation, neglect of care and supervision that resulted in the resident’s condition requiring medical intervention, the investigation revealed the following: R1 was admitted to the facility in the memory care unit on October 18, 2024, and was placed on hospice on October 2, 2024, prior to moving into the facility. R1 has a diagnosis of Senile Degeneration of the Brain, Atrial Fibrillation, and high blood pressure. R1 required full assistance such as transfers, escorting, and toileting per the Needs and Services Plan dated October 18, 2024. Per interviews conducted, four out of nine staff reported that the status checks were conducted every two hours and more if resident is a fall risk. The service plan notes R1 not requiring additional status checks although the facility staff were informed R1 routinely getting up at least two to three times to use the bathroom in the middle of the night at the time. Staff #2 (S2) was informed of the night routine during the pre-appraisal assessment conducted at R1’s home on October 7, 2024 at 3pm. On November 9, 2024, at approximately 8:03am, a caregiver discovered R1 in a prone position suspended from the bed rail by the neck. Per medical reports on page 200, dated November 9, 2024, R1 had sustained an unwitnessed fall in the evening, however the time of fall and the exact length of time R1 was suspended is unknown. During the investigation, it was determined that that residents are assigned to staff for monitoring. Staff #4 (S4) was assigned to check on R1 every 2 hours. S4 stated that they checked R1 at 2:30am on November 9th. Based on S4’s statement, S4 admitted not following the facility policy requiring them to check on the resident every two hours. The facility staff did not document the checks, and there was no way to verify that the checks were actually completed. After discovering R1 suspended, the caregiver notified Staff #1 (S1) reporting a “headlock,” and S1 arrived at the room at about 8:07am. S1 immediately attempted to reach Staff #2 (S2) by phone three times but was unsuccessful and subsequently called Staff #3 (S3) via FaceTime to report the incident. S3 instructed S1 not to move R1 and to call 911 instead. Paramedics arrived approximately 8:34am and discovered R1 in the same position, while the staff, instead of freeing the resident, were observed clearing the live ants from R1’s face, mouth, and body. Emergency Medical Services (EMS) reported that R1’s airway had been obstructed by the rail causing R1’s oxygen levels to drop and their face and neck to swell. Page 68 of the medical report dated November 10, 2024, confirms R1’s oxygen saturation was at 81% at the time of assessment and improved to 93% after R1 was placed on a non-rebreather mask. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Per Mayo Clinic, a healthy oximeter values often range from 95%-100% with values under 90% are considered low. Based on the medical assessment, page 129 indicates that R1 was diagnosed with acute respiratory failure with hypoxia and hypercarbia and sepsis which is contributed by impaired ventilation. Regarding the allegation, Facility has pests, LPA toured the facility during the initial visit conducted on November 14th, and no immediate health and safety threats were identified at the time of inspection. LPA observed live ants in the unit that R1 used to reside in and observed ants in other residents’ rooms. Based on the interviews, five out of ten staff interviewed confirmed the presence of ants in the facility. Out of the nine interviewed, three staff witnesses, and the medical responders who were present on scene witnessed the ants covering R1’s mouth, face, and body. Additionally, five out of the six residents interviewed witnessed ants in their respective rooms. The medical responders witnessed three staff trying to clean the ants from R1's face and body. Page 135 of the medical report also corroborates “ants crawling all over” R1. The investigation revealed that there were substantial evidence corroborating neglect/lack of care and supervision of R1 as staff failed to conduct their routine checks, initiate the 911 call timely, and to provide immediate rescue measures to aide in R1 who was in a painful position covered in live ants for an unknown amount of time throughout the night and continued to be in the same position for approximately 30 minutes after being discovered by staff. Therefore, based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Neglect of care and supervision that resulted in the resident’s condition that required medical intervention and Facility has pests are deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. Deficiencies are being cited on the attached LIC 9099D, and an immediate Civil Penalty (CP) is being assessed. See the attached LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) as per Health & Safety Code 1569.49(f). An exit interview was conducted with Executive Director Christine Chon, and a copy of this report including the LIC9099-Cs, LIC9099-D, LIC421IM, LIC811s, and the appeal rights were provided at the end of the visit.
2025-04-03Complaint InvestigationSubstantiatedType A · 2 findings
Plain-language summary
A complaint investigation found that staff were not properly trained to care for a resident's colostomy bag, which staff were draining and changing multiple times daily. When asked, staff could not confirm whether the resident was receiving home health services, and the facility's records showed the resident was actually on home health—a service the facility should have verified before admitting the resident. The facility failed to meet the required qualifications and training needed before accepting a resident with this medical condition.
“During interviews it was discovered a staff member was in a residents room for an extended period of time unauthorized. This is a health, safety and personal rights risk to residents in care.”
“This requirement is not being met as evidenced by: Interview confirmation and document review show caregivers who are not trained by a skilled professional are providing routine maintenance to a residents colostomy bag.”
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Regarding the allegation: Caregivers are not properly trained During interviews it was discovered one of the facility residents has a colostomy bag and staff are draining and changing the colostomy bag several times a day, everyday. The staff member was asked if the staff have been trained by a qualified professional to perform maintenance of the colostomy bag, and the staff member was not sure. The same staff member was then asked if the resident was on Hospice or Home Health. The staff member said the resident was not on hospice and was not sure if the resident was on Home Health. During the interview, the staff member called another staff member via walkie talkie, and asked if the resident with the colostomy bag was on Home Health. The staff answered, no. Later on, during the investigation it was revealed the resident is indeed on Home Health. A colostomy is an allowable health condition however, the licensee must meet the necessary requirements before the resident is admitted. Information gathered during interviews confirm the facility failed to do so in this situation. Based on the evidence gathered through interviews, and document review, the preponderance of evidence standard has been met, therefore, the above allegations are 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 were provided.
2025-02-13Other VisitType A · 1 finding
Plain-language summary
A state licensing analyst made an unannounced visit to investigate a complaint and found that hot water in a first-floor bathroom measured 150 degrees Fahrenheit, which exceeds the safe temperature limit. The facility's business office manager confirmed this temperature reading. The state cited a deficiency based on this finding.
“This requirement is not being met as evidenced by, LPA measured the hot water in the first floor bathroom of the facility lobby and it measures 150.0 degrees Fahrenheit. This poses an immediate health and safety risk to residents in care.”
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit. LPA met with Business Office Manager Kayli Carmarillo and explained the reason for the visit. LPA observed the See Something, Say Something poster (PUB 475) posted in the main lobby of the facility. During the investigation of complaint #22-AS-20250210154524 LPA measured the hot water in the first floor bathroom in the lobby of the facility. The hot water measured 150.0 degrees Fahrenheit. The Business Office Manager verified the temperature reading. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
2025-01-30Complaint InvestigationSubstantiatedType B · 1 finding
Plain-language summary
A complaint investigation found that dirty dishes were left on the kitchen counter, and a large pot of soup or stew sat uncovered on a warmer in the kitchen. Staff explained that residents bring their used dishes to the kitchen at night and in the morning, and photos confirmed both dirty and clean dishes were present, along with the uncovered pot. The facility was cited for this violation.
“This requirement is not being met as evidenced by photos that reveal dirty dishes and a pot of leftover food (soup/stew) was present in the kitchen while breakfast was being served.”
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During interviews, it was discovered the dirty dishes that were in the kitchen area were from residents who eat in their room at night, and in the morning the resident(s) will bring their used dishes to the kitchen and drop them off on the counter to be cleaned. Photos were provided and upon for further review of the photos, LPA observed dirty dishes in the kitchen as well as clean dishes in the kitchen at the time photos were taken. Further, after additional review of the photo, the amount of dirty dishes in the photo were consistent with the details provided during an interview with Staff 3 (S3). However, there was still a large pot of what appeared to be soup or stew, left out sitting on a warmer uncovered. Based on the evidence gathered through interviews, and photo review, the preponderance of evidence standard has been met, therefore, the above allegation is SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.
2025-01-28Complaint InvestigationMixedType B · 2 findings
Plain-language summary
This was a complaint investigation into a water shut-off for repairs on January 14-15, 2025. The facility failed to notify residents and families ahead of time that the water would be shut off, and did not provide hand sanitizers or wipes in residents' rooms and common areas during the outage, leaving residents unable to practice proper hand hygiene—though the facility did keep sanitizers in storage areas and some staff provided them on request. The allegation that the plumbing itself was in disrepair could not be substantiated, as the water issues were caused by necessary repairs to aging pipes and a boiler, which the facility attempted to expedite.
“Based on interviews and record review, six out of the seven staff and three out of the five residents confirmed no advance notice was given to residents and their representatives regarding the lack of water during the repair which poses a potential health, safety, or personal rights risk to persons in care.”
“Based on observations and interviews, hand sanitizer dispensers and/or wipes were not available except for selected rooms only accessible for staff and four out of the five residents corroborated not being able to wash or sanitize their hands during the repair which poses a potential health or safety risk to persons in care.”
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The investigation revealed the following: It is alleged that the facility did not notify residents and families of the water shut off. Per the interviews conducted, three out of the five residents confirmed no notice was given ahead of time regarding the water shut off on repair dates January 14, 2025 and January 15, 2025. Six out of the seven staff also corroborated with the allegation. Based on the review of the emails, ED was informed on January 7, 2025 at 12:06pm for the repair scheduled on the 14th allowing ample time for the residents and their families to be notified by the facility. Regarding the allegation, facility did not follow the infection control requirements, it is alleged that the facility did not maintain hand sanitizers or wipes for the residents to perform proper hand hygiene during the water shut off. Facility maintained sufficient supply of hand sanitizers in the medication rooms and supply rooms per inspection conducted on the 16th. Also observed in the housekeeping rooms, were barrels of clean water at each level available for cleaning and for resident use. Per observations, hand sanitizers and/or wipes were not observed in the residents' rooms and common areas making it inaccessible for residents and staff to sanitize their hands. Based on the interviews, four out of the five residents corroborated indicated not being able to wash or sanitize their hands with an alcohol based sanitizer and/or wipes while one resident maintained their own hand sanitizer in their room. Six out of the seven staff denied the allegation indicating that proper hand hygiene were practiced such as wearing gloves and using hand sanitizers while assisting residents while the water was shut off. Five out of the seven staff also confirmed providing hand sanitizer to the residents as needed. Based on observations and information obtained, it is determined that the residents were unable to practice proper hand hygiene during the repairs which could have been prevented if hand sanitizer dispenser stations were available and/or carried by the staff to deter theft and ensure easy access. Therefore, based on LPA's observations, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations, Facility did not notify residents and families of water shut off and Facility did not follow the infection control requirements are deemed SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D. An exit interview was conducted with Executive Director Dennis Robeniol, and a copy of this report including the LIC9099-D, and the appeal rights were provided at exit. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The investigation revealed the following: It is alleged that the facility plumbing is in disrepair. The water tested in the bathrooms were observed operable on January 16, 2025. During the tour conducted with MD Decon on January 16th, LPA observed three carpet stains caused by a water leak originating from the pipes running through the ceiling on the second floor. MD stated that the second floor leak is correlated to the leak from the boiler room. Upon inspection, LPA observed mineral buildup and rust on the isolation valves on the connecting pipes of the water boiler tanks which is caused by water corrosion and hard water per MD. MD stated that the the facility is running on a temporary boiler during the repair while the fittings on the pipes are being replaced and the boiler repaired. Based on the interviews conducted, five out of the five residents and seven out of the seven staff confirmed the water not working for several hours. Only one out of the five residents confirmed the water was turned off on these exact dates, January 14-15, 2025, which also corroborated by four out of the seven staff. Based on the review of the emails and job summary, no repair was scheduled and conducted on January 13th therefore the water was not turned off. The work order history documents facility was serviced on January 14th from 6am to 2pm per the job summary. MD indicated an additional day of repair was continued the following day. Email correspondences dated January 2, 2025 at 11:01am and 3:26pm reveal facility attempting to expedite the repair with the boiler company however could not be expedited due to "part availability and correct technicians/mechanics for each job." Based on the information obtained, repairs are required as a result of normal wear and tear. The pipes were in disrepair causing the water to be shut off during the repair. While facility tried to resolve the issues within a timely manner, the delay was due to scheduling conflicts with the boiler company, not the facility. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation, Facility plumbing is in disrepair, is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Dennis Robeniol, and a copy of this report was provided at exit.
2024-12-24Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that staff handled a resident roughly, but investigators found no evidence to support it. Both residents and all staff interviewed denied the allegation, and medical records showed the resident's behavior that evening—yelling, combativeness, and fear—were consistent with their documented medical condition; staff said they guided the resident by the arm toward the elevator to prevent a fall. The investigation found conflicting statements and insufficient evidence to prove the allegation occurred.
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Two out of the two residents did not corroborate the allegation indicating that they were not touched or grabbed inappropriately by staff. Five out of the five staff also denied the allegation indicating that the staff did not engage inappropriately with other residents including R1. Two out of the two staff that were involved in the incident indicated in their written statements that R1 displayed unwanted behaviors due to their medical condition on the evening of June 21st. The two staff indicated that R1 was guided towards the elevator and was supported using their arm to prevent R1 from falling. Based on the review of R1’s Physician’s Report dated August 16, 2023, the behaviors described in the interviews are consistent with the diagnosis documented on the medical report. Prior to the incident, R1 displayed exit seeking behaviors as well as yelling, being combative/aggressive, and showing fear of being kidnapped per charting notes dated March 22, 2024, and March 26, 2024. However, the investigation found conflicting statements, therefore, based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility staff handled resident in a rough manner is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Dennis Robeniol, and a copy of this report was provided.
2024-12-18Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that one resident punched another in the face and repeatedly hit them with a walker; investigators found that a lip injury did occurred, but the accounts differed on what happened and paramedics found no other injuries despite checking the resident's condition. The resident who was injured refused medical treatment and has a history of embellishing stories, and the facility's documentation did not support the claim of repeated walker strikes or injuries to the head or body. The complaint was unsubstantiated because there was not enough evidence to prove the full allegation occurred as described.
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It was alleged that R1 had been allegedly “sucker punched” on the right side of the face and was repeatedly hit with the walker by R2. Two out of the two residents, four out of the five staff, and two out of the four individuals that were interviewed confirmed observing R1 with a lip injury caused by the alternation but not to the torso or head. R2 also confirmed punching R1 on the mouth causing an injury to the lip area. However, R2 indicated that they had thrown the punch in return after being struck first but denied using the walker to hurt R1. Based on the staff interviews, four out of the five staff confirmed R1 refusing to seek medical treatment offered by the facility staff and the paramedics which was consistent with the incident report dated November 11, 2024 and Narrative Charting dated November 5, 2024. Based on the records that were reviewed, R1 is diagnosed with Dementia and may be “verbal and aggressive at times” according to the Physician’s Report dated August 30, 2024. The care level documented on the Resident Assessment dated October 1, 2024, requires no additional status checks as well as R2 per their Resident Assessment dated July 12, 2024. Routine checks of every two hours were required for R1 and R2 per Resident Care Director (RCD) Alysia Noriega. The two staff who were working the evening of November 4th, confirmed conducting status checks at the start of their shifts. The narrative charting notes R1 was hit on the head with a walker twice from both accounts, however there were "no signs of injury, bruising, pain, or bleeding" observed besides the lip and R1's "vitals were good" per the paramedic’s assessment. R1’s representative also did not corroborate with R1's statement of being repeatedly hit with a walker, as they had indicated that it would be fatal due to their medical condition. It was also revealed R1 having a history of embellishing stories. Based on the investigation, it is determined that although R1 has sustained an injury to the lip area, there were no evidence to prove that R1 had sustained additional injuries to the torso or head. Facility conducted routine checks and responded timely reporting the medical emergency to law enforcement and first responders. However, resident denied receiving medical treatment which is their personal right. The evidence obtained did not corroborate due to a lack of care and/or supervision. Therefore, based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Resident sustained injuries while in care is deemed UNSUBSTANTIATED. An exit interview was conducted with Memory Care Program Director Edwin Guzman , and a copy of this report and the LIC811 were provided at exit.
2024-12-12Other VisitType B · 2 findings
Plain-language summary
An unannounced case management visit in September 2024 found multiple maintenance issues: leaking pipes that had been ongoing since at least 2023 with trash cans placed in hallways to catch water, a broken pull cord in a second-floor bathroom, a thermostat locked behind a plastic case so residents could not adjust temperature (one resident was observed wearing a jacket and said he was cold), and two of four washing machines not working. The facility was cited for these deficiencies under California regulations, and facility management was notified of the violations and their appeal rights.
“This requirement was not met as evidenced by: The temperature in resident room 332A was observed to be 67 degrees F. Photos were taken.”
“This requirement is not being met as evidenced by: Observations made by LPA during two different unannounced visits. This poses a potential health and safety risk for residents in care.”
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to issue citations for deficiencies observed during unannounced visits made to the facility while investigating complaint control # 22-AS-20240909112643. On Tuesday, September 17, 2024: At 1:21pm, LPA Haley observed several trash cans in the hallway on the second floor. After speaking with two different staff members, it was confirmed pipes are leaking due to a plumbing issue that was resolved in the summer of 2023, and have been leaking for a while. Photos were taken. At 4:25pm, LPA Haley observed the pull cord in the bathroom on the second floor in disrepair and nonfunctional. Photos were taken. During today’s unannounced visit, while investigating complaint control number # 22-AS-20241205102328, while making observations in resident room number 332A, the room temperature was below regulation guidelines. One of the residents was observed in his room on the bed with a jacket on. The resident responded with I’m cold when asked how they were doing. LPA Haley observed the thermostat and it was covered with a plastic case. A key is needed to adjust the temperature. Photos were taken. Towards the end of the unannounced visit LPA discovered 2 of 4 facility washer machines are in disrepair. Photos were taken. As a result of today’s Case Management visit and observations made during the two unannounced visits, deficiencies will be cited per California Code of Regulation Title 22. An exit interview was conducted, and a copy of this report, LIC809D, and appeal rights were provided.
2024-12-12Complaint InvestigationSubstantiatedType A · 2 findings
Plain-language summary
A complaint investigation found that the facility missed giving medications to residents at scheduled times and then falsified medication records by backdating them after the fact—staff confirmed being asked to go back and fill out paperwork for medications that had already (or had not been) given. The facility did not dispute these findings, and the violations were substantiated based on staff interviews, resident accounts, and document review.
“Facility staff failed to administer medications as prescribed on more than one occasion for more than one resident. This poses a health and safety risk to residents in care.”
“Facility staff provided incomplete records with inaccurate information. Multiple staff were asked to go back and initial the Medication Administration Records (MAR) for medications previously administered and/or missed medications.”
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The complaint allegation was confirmed by Staff 3 (S3), Staff 4 (S4), and Staff 5 (S5). According to S3, Staff members have been let got as a result of medication errors. S4 and S5 both revealed 6:00am medications have been missed for two of the residents. During an interview with Resident 1 (R1), the resident confirmed not receiving medication on two different dates. R1 had detailed notes, and knew what medications were missed. Photos were taken of R1’s notes. Regarding the complaint allegation: Facility staff provided falsified documents During the investigation, 4 of 5 staff members provided information the supports the complaint allegation. According to S2, it was discovered med techs are asked to go back and fill out the Medication Administration Record (MAR) for medications already administered. S4 and S5 both confirmed they have been asked to go back and initial the MAR for medication that were already administered. During an interview with S3, it was discovered the MAR has been filled out after medication have been administered. S3 stated, we will bring it to them and give them a verbal and if it continues, we write them up. Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegations are 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 were provided.
2024-12-04Other VisitType B · 2 findings
Plain-language summary
This was the facility's required annual inspection, which found the building in good physical condition with working bathrooms, proper water temperature, adequate food and emergency supplies, and current fire safety certifications. Inspectors reviewed resident and staff files, medications, and interviewed residents with no discrepancies found. The facility was advised to ensure adequate emergency food and water supplies and to conduct quarterly evacuation drills for all staff shifts.
“Based on observations made during the annual inspection and interview confirmation, the licensee did not comply with the section cited above which poses a potential health risk to persons in care. POC Due Date: 12/13/2024 Plan of Correction 1 2 3 4 Executive Director Robeniol stated an order placed to stock the emergency food an water supply. ED Robeniol will email LPA Haley a copy of the invoice once the items are purchased no later than 1:00pm on the POC due date.”
“Based on record review, the licensee did not comply with the section cited above which poses a potential health and/or safety risk to persons in care. POC Due Date: 12/13/2024 Plan of Correction 1 2 3 4 Executive Director Robeniol agrees to schedule an emergency evacuation drill for staff on all shifts. ED Robeniol will schedule the drill and send LPA Haley the dates and times of the scheduled evacuation drill(s) no later than 1:00pm Friday, December 13, 2024. A copy of the sign in sheet for the evacuation drill will be emailed to LPA Haley after completion of the evacuation dirll.”
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Licensing Program Analysts (LPAs) Jerome Haley and Eboni Bentley arrived at the facility unannounced for the purpose to conduct the Required 1 Year Annual Inspection. LPAs were greeted and granted entry by one of the senior staff members on duty as the business/reception area was closed upon arrival. The facility is licensed with a capacity of 120 residents and maintains a hospice waiver of 20 residents. During the annual inspection, the resident census was 45. LPA Haley and LPA Bentley conducted a tour of the physical plant and observed the following: This is a two-story commercial building comprised of an Assisted Living (AL) Memory Care Unit. LPA’s inspected 8 random resident bedrooms which had all the required elements with ample lighting. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. The hot water temperature measured within the range of 105 -112.4 degrees Fahrenheit. LPAs inspected the kitchen and the dining area. A first aid kit with all the required elements was observed in the office of the Resident Care Coordinator (RCC) on the second floor. There’s also a first aid kit in the med room on the third floor. Facility maintains ample supply of two-day perishables food items and seven-day supply of non-perishables food items. Emergency food and water was observed. Cleaning chemicals and toxins was in a sotrage room on the second floor. Edison Fire Protection conducted an annual inspection of the Fire/Sprinkler system on February 12, 2024 which was verified on the inspection report. LPAs toured the outside grounds, there was sufficient seating and shading for the residents, and the walkways were free of obstruction. Continued on LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size posted in the entry way. Facility maintains a current liability insurance. Five resident files and five staff files were reviewed. No discrepancies noted. LPAs reviewed two staff files. No discrepancies noted. Interviews were conducted with seven out of eight residents as one resident refused. The two staff interviews were not conducted as they had ended their shift. The medications and the Medication Administration Records (MARs) were reviewed for 5 residents. No discrepancies noted. During the visit, LPA Haley advised the Executive Director on the importance of keeping enough emergency food and water, and the importance of conducting emergency evacuation drills at least quarterly for staff on each shift. Based on LPAs observations, deficiencies will be cited for violations of Title 22, and a Technical Advisory (TVs) will be issued as a result of today’s inspection. An exit interview was conducted and a copy of this report, and appeal rights were provided.
2024-11-27Other VisitType A · 1 finding
Plain-language summary
This was a follow-up inspection on April 27, 2026, to check whether the facility had corrected problems found during a complaint investigation in November 2024. The facility's call system for residents to summon help remains broken, and residents in memory care still cannot alert staff when they need assistance from their rooms. The state is issuing civil penalties because these problems were not fixed.
“Based on staff interviews, the licensee did not comply with the section cited above as the facility does not have an operational call signal system in memory care, which poses an immediate health and safety risk to persons in care.”
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection for deficiencies cited during Complaint Investigation conducted on November 14, 2024, into Complaint # 22-AS-20241112141855 . LPA met with Executive Director (ED) Dennis R obeniol and explained the purpose of the inspection. Deficiency 87303(a) was cited due to the facility not having an operational call signal system in memory care. During today’s visit, ED confirmed call system continues to be inoperable. Deficiency 1569(c) was cited due to residents being unable to alert staff for assistance from their specific living units. During today’s visit, ED stated residents continue to be unable to alert staff for assistance from their specific living units. Based on observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.Civil penalties for failure to correct are also being assessed An exit interview was conducted and a copy of this report and appeal rights was left at the facility.
2024-11-14Complaint InvestigationSubstantiatedType A · 1 finding
Plain-language summary
A complaint investigation found that the call system for assisted living residents on the second floor does not identify which unit is calling, and the auditory signal is not loud enough to hear from common areas, forcing staff to check rooms one by one to find residents who need help. Staff interviews revealed response times can be delayed because of this system limitation, and the facility was cited for not maintaining the call system in working order and not responding to residents in a timely manner. The facility received the report and information about appeal rights.
“Based on staff interviews, the licensee did not comply with the section cited above as the facility does not have an operational call signal system in memory care, which poses an immediate health and safety risk to persons in care.”
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One of four staff interviewed stated there is a call system for the assisted living residents on the second floor of the facility, but the call system does not identify the specific resident living unit. Interviews were conducted with four staff regarding the allegation staff do not respond to residents in a timely manner. Two of four staff interviewed stated that because the facility does not have a call signal system, staff may not respond in a timely manner and were unable to indicate how long a resident must wait to be assisted. One of four staff interviewed stated that although assisted living residents on the second floor of the facility have a call button, the call system does not identify the specific resident living unit and the auditory signal does not produce an auditory signal loud enough to summon staff; therefore staff must be within proximity to hear the auditory signal located in the hallways of the second floor of the facility, which is not auditory from the dining room or residents’ living units. Once staff hear the auditory signal they must go room to room to identify the resident calling, which results in a delayed response time. One of four staff interviewed stated that although the call system for the assisted living residents on the second floor does not identify the specific resident living unit staff respond in “three to five minutes.” Based on staff interviews conducted, LPA determined staff do not ensure call signal system is in good repair and staff do not respond to residents in a timely manner. The preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Two deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Resident Care Director (RCD) Alysia Noriega, and a copy of this report and appeal rights was provided at the end today's inspection.
2024-11-05Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint was investigated that alleged residents were being forcefully fed or dressed and improperly restrained. Staff and most residents denied the allegations, though one resident could not confirm or deny what happened, and inspectors found conflicting accounts that prevented them from determining whether violations occurred. The complaint was closed as unsubstantiated due to insufficient evidence.
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Five of five staff interviewed denied witnessing or having any knowledge of residents being forcefully fed or dressed. Four of five residents interviewed denied they are forcefully fed or dressed and denied witnessing any other resident being forcefully fed or dressed. One of five residents was unable to confirm or deny allegation. Due to conflicting information received during interviews conducted, LPA is unable to determine if facility used restraints on a resident or if facility did not accord residents with dignity. 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.
2024-10-30Other VisitType A · 3 findings
Plain-language summary
A state inspector made an unannounced visit to the facility on October 26, 2024 and toured seven resident rooms to follow up on previously cited deficiencies. The inspector documented observations through photos and will be issuing citations under California regulations. An exit interview was held with facility leadership and they received copies of the inspection report and information about their appeal rights.
“This requirement is not being met as evidenced by: On Saturday, October 26, 2024 around 12:00 noon, the window in room 310 did not have a safety lock to prevent the window from opening all the way. This poses a healthy and safety risk to residents in care.”
“This requirement is not being met as evidenced by: While inspectin resident bedrooms LPA Haley, Executive Director Robeniol, and the Resident Service Director observed resident room #212 missing a window screen. A photo was taken. This poses a potential safety risk to resident in care. This”
“This requirement is not being met as evidenced by: On Saturday, October 26, 2024 there was no administrator or designated back up administrator in the building. This poses a potential health, safety, and personal rights risk to residents in care.”
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to issue citations for deficiencies observed on Saturday, October 26, 2024 around 12:00 noon. During the case management visit, LPA Haley toured the interior of the facility and made several observations. During the tour with Executive Director Robeniol and the Resident Services Director, LPA Haley entered 7 resident rooms: four rooms on the third floor, including room 310 and three rooms on the second floor. Photos were taken. As a result of today’s Case Management visit and observations made Saturday, October 26, 2024, deficiencies will be cited per California Code of Regulation Title 22. An exit interview was conducted, and a copy of this report, LIC809D, and appeal rights were provided.
2024-10-30Complaint InvestigationSubstantiatedType B · 1 finding
Plain-language summary
A complaint investigation was conducted at this facility. The investigation found that the facility violated California regulations, and violations are being cited. An exit interview was held with facility staff, who received a copy of the report and information about appeal rights.
“This requirement is not being met as evidenced by: Facility staff failed to provide requested records to the responsible person for resident 1 (R1). This poses a potential personal rights risk to residents in care.”
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Based on the evidence gathered through interview 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 were provided.
2024-10-09Complaint InvestigationNo findings
Plain-language summary
A complaint alleged the facility admitted a resident without proper legal consent. The investigation found that the resident had properly signed a durable power of attorney form granting all necessary powers, which was notarized and dated May 6, 2023. The allegation was unfounded.
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R1 initialed the line in front of (N) and ignored all the other lines in front of the other powers. Line in stated the following: (N) ALL OF THE POWERS LISTED ABOVE. R1 signed and dated the California General Durable Power of Attorney agreement on May 6, 2023. The agreement was signed by the POA, validated by a notary public and stamped twice with the notary’s name and commission number. Based on the information gathered during the investigation through interview and document review, the following allegation: Facility admitted resident without legal consent, 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.
2024-06-10Complaint InvestigationSubstantiatedType A · 1 finding
Plain-language summary
A complaint investigation found that the facility violated state regulations. An exit interview was held with facility staff, who received a copy of the report and information about their right to appeal.
“This requirement is not being met as evidenced by interview confirmation and document review that reveal the Administrator is not present when medication is being destroyed and overnight staff are destroying medication. This poses a health and safety risk to residents in care.”
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Based on the evidence gathered during 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, Division 6. An exit interview was conducted and a copy of this report and appeal rights were provided.
2024-04-09Other VisitType A · 1 finding
Plain-language summary
The state conducted a follow-up visit to investigate an incident reported by the facility in March 2024. Inspectors interviewed staff and a resident, reviewed documents, and found violations that will be cited. The facility was informed of the findings and given information about how to appeal.
“This requirement is not being met as evidenced by staff interviews and document review that confirmed, a caregiver pinned Resident 1 (R1) down to the bed and held R1 down using a knee and hand to the upper chest area. This poses an immediate health and safety risk to residents in care.”
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to follow up on an incident report sent to the Regional Office dated March 20, 2024. During the visit, LPA Haley conducted interviews with facility staff and one resident to gather additional details on the incident reported to the Regional Office. During the visit, relevant documents for were provided. As a result of today’s case management visit and the information gathered through staff interviews, deficiencies will be cited. An exit interview was conducted and a copy of this report and appeal rights were provided.
2024-02-28Complaint InvestigationNo findings
2024-01-09Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that facility staff were not properly reporting incidents and that staffing levels were insufficient. Investigators reviewed incident reports, interviewed staff and family members, and found documentation showing that altercations involving residents were being reported to managers, families, and physicians, and that the facility maintains adequate staffing with 6-8 staff members per shift during the day and evening, and 5 staff members overnight. The complaint could not be substantiated based on the evidence gathered.
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A review of the incident reports involving R1 revealed facility staff was present to witness the altercation or present immediately after the incident to separate the residents and help resolve the issue and calm the residents down. Staff will also try to figure out what triggered the incident to prevent altercations in the future. Regarding the allegation: Staff are not properly reporting all incidents. 0 of 11 individuals could provide evidence to support the allegation, and family members of R1 shared information that contradicts the complaint allegation. Family members of R1 confirmed the family was contacted by facility staff several times regarding altercations with other residents. A review of incident reports and charting notes show incidents involving resident altercations were documented, incident reports were written, and the incidents were reported to facility managers, residents’ family, and physicians. During interviews with facility staff members, they all confirmed they document the incident and notify appropriate parties including family and physicians. Regarding the allegation: Staffing is insufficient in quantity to meet residents needs. During an interview with a facility staff member, it was discovered the facility is fully staffed. 6 caregivers and 2 med tecs are scheduled to work the AM and the PM shifts. During the overnight shifts, 4 caregivers and 1 med tech is scheduled to work. Staff are responsible for providing care for all residents, if it’s discovered a resident needs more care due to their behavior or additional care needs, Beach Terrace will contact the family to discuss additional care options for that resident including one-to-one care. During interviews with staff, it was discovered care staff will immediately separate residents involved in a conflict, staff will keep the residents away from each other, and if a resident continues to have altercations with peers the resident’s physician will be notified. Based on the information gathered during the investigation through interviews, document review, and observations, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, all allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was provided.
2023-12-13Complaint InvestigationNo findings
Plain-language summary
A complaint investigation found no violations at this facility. Inspectors interviewed staff, reviewed documents, and toured the laundry room, and confirmed that residents receive clean linens daily, with soiled linens washed the same day, and that residents participate in activities appropriate to their abilities.
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Residents are separated into two different groups. Residents who are more active are separated from residents who are not as active. The active residents take part in activities like exercising or balloon toss while the group with the less active residents sit at the table and participate in sensory activities like coloring or a laundry activity. Regarding clean linen. 6 staff members confirmed residents are provided clean linen daily. Residents keep their clean linen in their room. According to Executive Director Jensen, linen is monitored daily, and families are told to bring more than one set of linen for the residents. According to Staff 1 (S1), if a resident doesn’t have an extra set of linens, the soiled linen is removed and cleaned immediately. During an interview with Staff 5 (S5) it was confirmed laundry is done daily and if a resident’s linen is soiled it’s cleaned the same day. S5 lead LPA Haley on a tour of the laundry room and during the tour of the laundry room, washer machines were in use. Based on the information gathered during the investigation through interviews, document review, and observation, the allegations mentioned above are deemed UNFOUNDED, meaning the allegations are 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.
2023-11-16Other VisitType B · 1 finding
Plain-language summary
During a case management visit following up on a previous complaint investigation, inspectors found that the facility failed to report multiple falls that occurred between January and June 2023, and also failed to report a resident's death in June 2023 to the state as required. The facility's records showed the last reported fall was in December 2022, before the resident was placed on hospice care. Deficiencies will be cited as a result of these findings.
“This requirement is not being met as evidenced by the facility failing to report documented falls by Resident 1 and the death of Resident 1 on June 28, 2023. The Region Office did not received any incident reports for the falls during the time period of January 2023 – June 2023, or R1’s death on June 28, 2023.”
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Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20230306125953. During the complaint investigation mentioned above, it was discovered Resident 1 (R1) had several falls that were not reported to the department. Hospice document review revealed R1 had several falls between January 2023 – June 2023. The last fall reported to the Department was a fall that took place on December 25, 2022, before R1 was placed on hospice. No other falls were reported to the department. In addition to the facilities failure to report R1’s falls, R1 passed away June 28, 2023 and the death was not reported to the department as required. As a result of today’s Case Management visit, deficiencies will be cited. An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.
2023-11-16Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A family member and hospice employee complained that staff responded too slowly to a resident's needs and spoke inappropriately to residents. Staff members, family members, and hospice employees interviewed by the state could not confirm these allegations occurred, and the investigator found insufficient evidence to prove or disprove the complaints.
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According to one of R1’s family members, R1 was mute and could not form a complete sentence, and according to one of the hospice employees R1’s responses were not reasonable or appropriate, you could tell R1 had cognitive issues. Regarding the allegation: Staff did not respond to a residents needs timely 6 of 11 individuals denied the allegation. According to Staff 1, the caregivers go above and beyond when providing care to the residents in the community. Staff 4 says the staff are trying to pick up the speed of things and there’s a lot of training provided. 2 of R1’s family members had concerns about the care being provided but said the care for the resident improved once the resident was placed on hospice. Regarding the allegation: Staff speak inappropriately to residents in care All 6 staff members interviewed denied the allegation above. 2 family members of R1 and 2 hospice employees were unable to corroborate the allegation above. During interviews, Staff 5 says the residents are happy and there are no issues. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations 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 violations occurred; therefore, all allegations are deemed Unsubstantiated.
2023-10-25Other VisitType B · 1 finding
Plain-language summary
During a follow-up investigation visit, inspectors found that Beach Terrace Memory Care did not report a resident's fall and hospitalization to the state as required. A resident fell on August 23, 2023, and was hospitalized with a broken neck (cervical vertebral fracture), but the facility failed to file the required incident report within 7 days. The facility will be cited for this failure to report.
“This requirement is not being met as evidenced by the facility failing to report R1's fall and injury. This poses a potential health and safety risk to residents in care.”
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During the investigation into complaint control number 22-AS-20230825151110 it was discovered the facility failed to report the fall and/or injury to the Regional Office. All serious incidents should be reported to the Regional Office within 7 days. Beach Terrace Memory Care failed to report a resident was sent to the hospital after an unwitnessed fall with complaints of pain to the back and neck. The resident returned to the facility on August 25, 2023, with a diagnosis: Injury Due to Fall – Cervical (Neck) Vertebral Fracture. There was no incident report regarding Resident 1’s fall August 23, 2023, sent to the Regional Office. As a result of today’s Case Management visit, a deficiency will be cited. An exit interview was conducted and a copy of this report and appeal rights were provided.
2023-10-25Complaint InvestigationSubstantiatedType A · 1 finding
Plain-language summary
A resident with a history of falls fell in a common area on August 23, 2023, and was found on the floor with a neck fracture; no staff member witnessed the fall, and there was no plan in place to help prevent falls for this resident. The facility could not explain why staff were not present or supervising in the area where the resident fell. The complaint was substantiated.
“This requirement was not met as evidenced by R1 who is a known fall risk, having an unwitnessed fall in a common area of the facility. This poses a potential health and safety risk to residents in care.”
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The fall was unwitnessed and there was not much detail about how the incident occurred. Interviews and document review revealed the resident was found on the floor with eyes closed and expressed pain to the back and neck to paramedics. R1’s after visit summary from Kaiser dated August 24, 2023 revealed a diagnosis of Cervical (neck) Vertebral Fracture. On August 23, 2023, when R1 fell and sustained an injury to the neck, none of the staff on duty witnessed the fall. It’s unclear what the resident was doing at the time of the fall, it’s unclear who was present when R1 fell, and it’s unclear why none of the staff on duty was present when R1 who has a history of falling, fell in a common area. Witness interviews, as well as document review reveal R1 has had several falls. Witness interviews revealed there was no plan and/or directions given to or discussed with staff to prevent R1 from falling. Based on the evidence gathered during 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, Division 6.
2023-07-03Other VisitType B · 1 finding
Plain-language summary
A state licensing analyst visited the facility following an investigation into unreported incidents where a resident displayed aggressive behavior in March 2023. The facility failed to report these incidents to the state as required by law. The facility received a citation for this violation, and staff were notified of their appeal rights.
“This requirement is not being met as evidenced by review of incident reports sent to the department. There was no incident report that mentioned R1 sent to the regional office. LPA spoke with staff and they could not provide the incident reports that were sent to the Regional Office.”
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Licensing Program Analyst (LPA) Jerome Haley made conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20230404094217. During the complaint investigation mentioned above, it was discovered there were incidents involving aggressive behavior displayed by Resident 1 (R1) that were not reported to the department. The incidents took place in March 2023 and there is no evidence of any of the incidents were reported to the department as required. As a result of todays visit, a deficiency will be cited during today's Case Management visit. An exit interview was conducted and a copy of this report, LIC809D, LIC811, and appeal rights were provided.
2023-07-03Complaint InvestigationNo findings
3 older inspections from 2022 are not shown above.
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