198603118-6-30-2023-11-AS-MVAO-CWWSAU-20231024134256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603118
Report Date: 06/30/2023
Date Signed: 06/30/2023 05:45:44 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
06/23/2023 and conducted by Evaluator Jeremiah Randle

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230623081122

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: 110	DATE:	06/30/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Camille Bughaw LVN. Memory Support Director.		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff not providing a safe environment for resident(s) in care.

INVESTIGATION FINDINGS:

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Allegation: Staff not providing a safe environment for resident(s) in care.
On 6/30/2023 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced 10 Day complaint visit at the facility listed above. LPA arrived at facility and was greeted by Camille Bughaw LVN. Memory Support Director. LPA explained the purposed of the visit is to deliver findings on the allegation listed above.
The investigation consisted of the following:
LPA observed facility, as well as common areas of the facility. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair, LPA reviewed pertinent documents pertaining to the investigation. The following documents were gathered: Staff and Client Rosters, file for resident (R1) and any other pertinent documentation needs and service, physician report, residency agreement, for R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

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-20230623081122

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: 06/30/2023

NARRATIVE

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On 06/30/2023 LPA Randle interviewed (S1) and resident (R1). LPA requested, received, and reviewed the following information: file of R1, Staff roster, Resident roster, and other documents relevant to the investigation. On 06/30/2023, LPA interviewed Camille Bughaw LVN and Resident (R1). LPA requested and reviewed pertinent documents pertaining to the investigation. LPA received the following pertinent documents pertaining to the investigation: Resident Roster, Staff Roster, Admissions Agreement, Needs and Services Plan, LPA reviewed Staff schedule. LPA interviewed staff (S1-S10) and residents (R1-R6). regarding allegation listed above.
The investigation revealed the following:

Allegation: Staff not providing a safe environment for resident(s) in care.

On June 30, 2023, LPA interviewed Camille Bughaw LVN Memory Support Director. (S1). LPA asked S1 if S1 was aware of the Staff not providing a safe environment for resident(s) in care. S1 stated that S1 was aware of the incident and denied the allegation. S1 stated that resident R1 did indeed complain about a resident speaking too loud to her and she did feel unsafe at the time. S1 stated to LPA that S1 investigated the incident and found R1 had a verbal altercation with another resident regarding seating in the dining area and this was a single episode no other issues have occurred between the residents. LPA interviewed staff S2 and S2 confirmed that R1 had a verbal altercation with another resident regarding seating in the dining area where voices were raised, this was a single episode, and the issue was resolved.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230623081122

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: 06/30/2023

NARRATIVE

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Continued

LPA interviewed R1, R1 admitted R1 had a verbal altercation with another resident regarding seating in the dining area where voices were raised, this was a single episode, R1 stated that R1 has not had any issues after the episode, however R1 stated “I did feel unsafe at the time”. LPA asked R1 does she feel safe living in the facility? R1 replied “yes I feel safe”.
LPA interviewed staff (S2-S10) and staff denied the allegation Staff not providing a safe environment for resident(s) in care and provided no reported incidents from any source of residents feeling unsafe. LPA interviewed residents (R2-R6) regarding allegation listed above - Staff not providing a safe environment for resident(s) in care. The residents interviewed denied the allegation and reported they had not experienced any issues of feeling unsafe or staff not providing a safe environment.
Findings

Based on information gathered, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099 was provided to Camille Bughaw LVN. Memory Support Director

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023

LIC9099 (FAS) - (06/04)

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