198603118-11-14-2022-11-AS-JRAE-CL72XG-20221114164708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603118
Report Date: 11/14/2022
Date Signed: 11/14/2022 04:47:22 PM

Document Has Been Signed on 11/14/2022 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CLEARWATER AT SOUTH BAY		FACILITY NUMBER:	198603118
ADMINISTRATOR:	JILL TUCKER		FACILITY TYPE:	740
ADDRESS:	3210 & 3212 W SEPULVEDA BLVD		TELEPHONE:	(424) 488-6340
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	137	CENSUS: 116	DATE:	11/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Administrator Michele Johnson		TIME COMPLETED:	05:00 PM

NARRATIVE
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	Licensing Program Analyst Jeremiah Randle conducted an unannounced visit to the facility for purpose of required annual inspection. Today's visit, LPA met with the administrator Michele Johnson and explained the reasons of the visit and she also assisted with the visit. The facility is licensed for 137 non-ambulatory residents and 13 of which can be bedridden age 60 and above. Currently the facility has 116 residents and there's no resident with restricted health conditions. Nine (9) residents are on hospice and (6) are bedridden. The last Fire inspection was conducted on 09/20/22 with the contractor Fire Safety Service INC. Structure: The facility is two building structures, one building is designated for Assisted Living and Memory Care residents and consists of two (2) floors and the other building consists of Memory Care residents and has three (3) floors. There are a total of 54 Assisted Living units and 55 Memory Care units. room, kitchen, TV room, multipurpose room, business office, beauty salon room, emergency food supply room, multiple storage rooms, janitor closet, medication stations, caregiver stations, employee lounge, therapy room and four (4) outside patio with table and sufficient chairs and putting green. There's no body of water around the building. All outdoor and indoor passageways are free of obstruction. Bedrooms Residents: Bedrooms are single and double for one or two residents. Each room has required furniture and adequate lighting. Each room has alarm system and they are all working properly. Bathrooms: All the bathroom has a working toilet, wash basin and shower. During the visit, LPA observed there's nonskid surfaces in the shower areas.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CLEARWATER AT SOUTH BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 11/14/2022

NARRATIVE

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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in the laundry room.

LPA reviewed residents and staff files, medication and First aid kit.

Medications, First-Aid Kit & Book:
The medications are centrally stored and locked in the medication station and is only available for staff to use and inaccessible to clients. LPA also reviewed the first aid kit and it included all the required supplies and the book is also updated.

Clients & Staff Files:
The residents files are stored and locked at the medication station and the staff files are stored in the administration office. On today's visit, LPA reviewed staff files and all have required documents include current first aid certificate and required training. LPA also reviewed resident files and all included updated needs and service plan, admission agreement and physician report and TB test result.
Emergency Phone Numbers, Exit Plan & Menu:
Readily available for review in the office of the administrator at the front door of facility. The facility has Fire Extinguishers, all fully charged and Fire System in both buildings.

Food Service
Dishes, cups, and flat ware are stored in the kitchen and inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in the kitchen which residents are not allowed to go into the kitchen. Food supply adequate stored in the kitchen and consists of the following: 2 days perishable and 7 days non-perishable per resident. Dishwasher in kitchen properly installed and functioning.

Smoke Detectors:
Each bedroom and common area has smoke detectors and carbon monoxide detectors and they are all interconnected, and they are all working properly.

Appliances:
Oven, microwave, washer, and dryer are all operational. There are walk-in refrigerators and two (2) freezer in the facility for additional food storage.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CLEARWATER AT SOUTH BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 11/14/2022

NARRATIVE

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Toxins:
All the cleaning solutions are locked and stored in the janitor closet which are inaccessible for residents.

Water Temperature:
The hot water temperature tested at the 15 bathrooms that LPA inspected between mandated temperature not exceeding 120f degrees .

Medications, First-Aid Kit & Book:
The medications are centrally stored and locked in the nurse stations and is only available to staff. LPA inspected The first aid kit and it's stored in the nurse station

Clients & Staff Files:
Staff and residents files are stored in the administration office, during the visit LPA inspected residents' files and they all have required documents included admission agreement, updated physician report, TB test and needs and service plan. LPA inspected seven (7) staff files and they all have required documents include health screening, TB test result, required training hours and updated first aid certificate.

Fire Drill:
The last fire drill was conducted 09/2022 fire system serviced 10/2022 per administrator.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Administrator Michele Johnson, Program Director and copy of report provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022

LIC809 (FAS) - (06/04)

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