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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320602
Report Date: 06/24/2026
Date Signed: 06/25/2026 08:44:00 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2026 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20260618084007
FACILITY NAME:LEONARD ON BEVERLY A CLEARWATER COMMUNITY, THEFACILITY NUMBER:
198320602
ADMINISTRATOR:FLAHERTY, TRACYFACILITY TYPE:
740
ADDRESS:8070 BEVERLY BLVDTELEPHONE:
(213) 808-0170
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:124CENSUS: 36DATE:
06/24/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tracy FlahertyTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not properly supervise resident while away from the facility.
INVESTIGATION FINDINGS:
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On 06/24/2026, LPA Pamela Bunker conducted an initial visit to gather information regarding the allegation mentioned above. LPA met with Tracy Flaherty, Executive Director, and explained the purpose of today's visit. LPA was granted entry to the facility.

The investigation consisted of the following: On 06/24/2026 at 12:30 p.m.., the Department requested and reviewed resident's records and obtained copies of the following documents: Personnel Report (06/17/2026), Resident Roster (06/24/2026), Admission Agreement (05/04/2026), Identification and Emergency Information (04/10/2026), Physician's Report (04/08/2026), Medical Assessment (06/12/2026), Consent Forms (03/09/2026), Functional Capability Assessment (06/24/2026), Preplacement Appraisal Information (05/04/2026), Appraisal, Needs and Service Plan (05/12/2026, Personal Rights (03/09/2026), Text Messages (05/23/2026), Interviews were conducted with Staff Members #1 and #4 (S1-S4) as well as with residents #1 through #3 (R1-R3).
See continued LIC9099-C page 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20260618084007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LEONARD ON BEVERLY A CLEARWATER COMMUNITY, THE
FACILITY NUMBER: 198320602
VISIT DATE: 06/24/2026
NARRATIVE
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Continued LIC9099-C page 2.

Investigation revealed the following:
Allegation: Staff did not properly supervise a resident while away from the facility.

On June 24, 2026, between 12:30 p.m. and 4:30 p.m., the Department conducted interviews with Staff #1 through Staff #4 (S1–S4). 4 out of 4 staff members reported that the staff properly supervise residents when they are away from the facility. Staff stated that the resident in question has mild dementia and that the physician’s order indicates the resident may be unsupervised.

4 out of 4 staff members also stated that residents are never left unsupervised and reported that they were not aware of the hair salon attendant running behind schedule or that there would be a one-hour wait before the resident’s appointment could begin. Staff reported that hair salon employees are not responsible for providing care or supervision to residents.

Additionally, all four staff members stated that residents are provided with a safe, healthful, and comfortable environment, and that staff provide the necessary care and supervision to meet each resident’s needs. All four staff members denied the allegation.

On June 24, 2026, between 12:30 p.m. and 4:30 p.m., the Department interviewed Residents #1 through #3 (R1–R3). When asked whether staff properly supervise residents while away from the facility, 3 out of 3 residents stated that staff do provide proper supervision and do not leave residents unattended.

R1 reported that staff have never left her alone at the hair salon and that staff always wait in a chair until her appointment is finished. R1 also stated that when she schedules her hair appointments, she has never experienced a one-hour wait due to the salon being busy with multiple clients.

3 out of 3 residents stated that staff provide a safe environment and offer appropriate care and supervision based on each resident’s individual needs. Each resident confirmed that they feel safe in the facility and that staff maintain a respectful and supportive atmosphere. All three residents denied the allegation.



See continued LIC9099-C page 3
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20260618084007
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LEONARD ON BEVERLY A CLEARWATER COMMUNITY, THE
FACILITY NUMBER: 198320602
VISIT DATE: 06/24/2026
NARRATIVE
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Continued LIC9099--C page 3

On June 24, 2026, the Department also reviewed the resident records, including the physician’s report dated April 8, 2026, which indicates that the resident is able to leave the community unsupervised. In addition, staff received an email and text messages from the resident’s responsible party on May 23, 2026, providing instructions regarding the resident’s salon appointment and confirming that the resident may leave the community.

Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated.

There were no deficiencies cited.

LPA Bunker provided Tracy Flaherty, Executive Director, with copies of the LIC9099 and LIC9099-C
Complaint Investigation Reports.

An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3