198320602-6-17-2026-11-AS-EMAZ-DW8NST-20260722104339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320602
Report Date: 06/17/2026
Date Signed: 06/17/2026 12:40:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2026 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260608185058

FACILITY NAME:	LEONARD ON BEVERLY A CLEARWATER COMMUNITY, THE		FACILITY NUMBER:	198320602
ADMINISTRATOR:	FLAHERTY, TRACY		FACILITY TYPE:	740
ADDRESS:	8070 BEVERLY BLVD		TELEPHONE:	(213) 808-0170
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	124	CENSUS: 32	DATE:	06/17/2026
		UNANNOUNCED	TIME BEGAN:	10:02 AM
MET WITH:	Tracy Flaherty		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff forced resident to take insulin.
Staff yells at other staff in the presence of residents.

INVESTIGATION FINDINGS:

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On 06/17/2026, the department conducted an initial complaint visit to the facility and was greeted by Tracey Flaherty, Executive Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegations mentioned above.

The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R3). The department received the following documents: Personnel Report (Dated: 06/01/2026), Resident Roster (Dated: 06/17/2026), ID/Emergency Information (Dated: 04/06/2026), Physician’s Report (Dated: 03/20/2026), Resident Service Plan (Dated: 05/15/2026) and Medication Administration Record (Dated: 06/01/2026-06/17/2026) from the facility.

Report Continued On LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260608185058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LEONARD ON BEVERLY A CLEARWATER COMMUNITY, THE	FACILITY NUMBER: 198320602
	VISIT DATE: 06/17/2026

NARRATIVE

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The investigation revealed the following: Allegation #1- Staff forced resident to take insulin.

The details of the complaint alleged that the facility staff violates residents’ right by forcing them to take their insulin against their will. On 6/17/2026, from 09:30am-12:30pm, the department interviewed staff (S1-S4) and residents (R1-R3) regarding the allegation. 4 of 4 staff denied the allegation that Staff forced resident to take insulin. All staff stated that they have never forced any resident to take any insulin or other medication against their will. Staff stated that the residents have a right to refuse medication and it is not the policy of the facility to force them to do anything.

The department interviewed residents (R1-R3) about the allegation and 3 of 3 residents that were interviewed stated that the staff has never forced them to take any insulin or other medications against their will and have no knowledge of any other residents being forced to take medications.

The department reviewed the ID/Emergency Information (Dated: 04/06/2026), Physician’s Report (Dated: 03/20/2026), Resident Service Plan (Dated: 05/15/2026) and Medication Administration Record (Dated: 06/01/2026-06/17/2026) and observed that there is one resident who takes insulin and they have glucose monitoring four times per day, injection monitoring three times per day, and are consistent in taking their insulin medication.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff forced resident to take insulin. 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 allegation is Unsubstantiated.

Report Continued On LIC9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260608185058

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LEONARD ON BEVERLY A CLEARWATER COMMUNITY, THE	FACILITY NUMBER: 198320602
	VISIT DATE: 06/17/2026

NARRATIVE

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Allegation #2-Staff yells at other staff in the presence of residents.

The details of the complaint alleged that the facility administration is unprofessional, yells at staff members in front of residents, and forces them to perform functions above their professional scope. On 6/17/2026, from 09:30am-12:30pm, the department interviewed staff (S1-S4) and residents (R1-R3) regarding the allegation. 4 of 4 staff denied the allegation that Staff yells at other staff in the presence of residents. All staff stated that they have no knowledge of anyone in administration or anyone else yelling at staff members in the presence of their residents. They also stated that they have never forced anyone to perform duties that they were not trained to do; and they always conduct themselves in a professional manner while working at the facility.

The department interviewed residents (R1-R3) about the allegation and 3 of 3 residents that were interviewed stated that they have never witnessed any staff member or executive being unprofessional in their presence. They also stated that they have not witnessed nor heard any staff member yelling at another staff member in the facility.

Based on interviews, there is insufficient evidence to support the allegation that Staff yells at other staff in the presence of residents. 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 allegation is Unsubstantiated.

No deficiencies were observed and no citations were issued for this complaint investigation.

An exit interview was conducted with Tracey Flaherty, Executive Director, and a hard copy of this Complaint Investigation Report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026

LIC9099 (FAS) - (06/04)

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