198603118-9-4-2025-11-AS-EMAZ-DLYNN8-20250929103618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 09/04/2025
Date Signed: 09/04/2025 05:33:49 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, 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
08/26/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20250826092317

FACILITY NAME:	CLEARWATER AT SOUTH BAY		FACILITY NUMBER:	198603118
ADMINISTRATOR:	PAUL GOZON		FACILITY TYPE:	740
ADDRESS:	3210 & 3212 W SEPULVEDA BLVD		TELEPHONE:	(424) 488-6340
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90505
CAPACITY:	137	CENSUS: 101	DATE:	09/04/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Paul Gozon		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not ensure air conditioner was working properly

INVESTIGATION FINDINGS:

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On 09/04/2025, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Paul Gozon, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

The investigation consisted of the following:

During today's visit LPA inspected the facility, interviewed Staff S1-S8, interviewed Residents R1-R10, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Work Orders, and invoices for C&M Mechanical dated 05/29/2025, 07/09/2025, 07/25/2025, 08/12/2025, 08/15/2025, and 08/29/2025.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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-20250826092317

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: CLEARWATER AT SOUTH BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 09/04/2025

NARRATIVE

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Allegation: Staff did not ensure air conditioner was working properly
The allegation alleges the facility is not kept at a comfortable temperature and the air condition is not working properly.
During record review, LPA received and reviewed invoices from C&M Mechanical dated 05/29/2025, 07/09/2025, 07/25/2025, 08/12/2025, 08/15/2025, and 08/29/2025. During the visit conducted on 08/29/2025 the technician inspected all rooms with temperature complaints to verify the status of fan coils. The technician found no error codes on the AC units specified rooms. The technician observed that the fan coils in all rooms with temperature complaints were turned off at the thermostats. Additionally, the technician observed some of the rooms had open windows and blinds, contributing to the heat issue. During the visit on 08/12/2025, the technician observed the fan coil seemed closed due to pipe temperature not changing in rooms 207, 203, and 201. Room 101 had closed ports. The technician observed a loose not on ball valve. The technician tightened the nut and made sure the ball valves were opened. On 08/05/2025, 08/08/2025, and 08/12/2025 filters were changed, and the condenser coils were checked and cleaned. On 07/25/2025, the technician checked room 204 whose thermostat was set to off, when turned on, the thermostat setting was on heating. It was switched to cooling, then functioned properly. The technician checked Room 213 and observed the thermostat was on heating. It was switched to cooling and it functioned properly. On 07/09/2025, the technician checked room 213 and observed the thermostat was on heating. It was switched to cooling and it functioned properly. On 05/29/2025, room 107 had an error code. The technician changed the main PCB board, and the error cleared. In room 112 the motors were going bad. The technician changed the motor and the main PCB board for fan coil. On 05/06/2025, the technician checked the main units on the roofs. The technician observed one unit was not getting power due to the breaker not fully in the on position. The technician conducted a diagnostic and did not find any additional issues.
During the facility tour, LPA took the temperature of all common areas and eleven resident rooms. The following temperatures were recorded in the assisted living lobby the temperature measured 74.3-degrees, the dining room measured 73.6-degrees, the activity room measured 72.1-degrees, the first-floor hallways measured 75.3, 73.2, and 74.3-degrees, and the second-floor game room measured 75.6-degrees Fahrenheit. The following rooms temperature was measured in the assisted living, room 103 measured 75.5-degrees, room 108 measured 76.4, room 209 measured 77-degrees, room 215 measured 76.6-degrees, 235 measured 77.3-degrees, and room 242 measured 70.7-degrees Fahrenheit. The following temperatures were measured in the Memory Care Unit, the hallway measured 75.2-degrees, the

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20250826092317

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: CLEARWATER AT SOUTH BAY	FACILITY NUMBER: 198603118
	VISIT DATE: 09/04/2025

NARRATIVE

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dining room measured 73.0-degrees, and the activity area measured 76.1-degrees. The following rooms temperature was measured in the memory care unit, room 117 measured 76.6-degrees, and room 118 measured 73.7-degrees Fahrenheit. The following temperatures were measured in the Clearbrook building first-floor common area measured 73.2-degrees, the second-floor common area measured 74.3-degrees, and the third floor measured 71.6-degrees Fahrenheit. LPA observed all resident rooms have a thermostat to control the temperature in their room. LPA observed thermostats accessible in common rooms.
During interviews with Staff S1-S8, were asked if there have been any issues with the air conditioning in the building, two (2) out of eight (8) stated there was an issue with one of the units that has been repaired. Additionally, during interviews with Staff S1-S3, were asked if the HVAC system is maintenance, three (3) out of three (3) stated it is maintenance quarterly.
During interviews with residents R1-R10, were asked if the air conditioning is functioning properly in their room, eight (8) out of ten (10) stated there are no issues with their air conditioning. Additionally, residents R1-R10 were asked if the facility is maintained at a comfortable temperature, ten (10) out of ten (10) stated the facility is kept at a comfortable temperature. Three (3) residents stated the activity room can get too cold.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Executive Director, Paul Gozon, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

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